i^       /O 


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|P^U  L  M  O  N  A  R  Y 
TUBERCULOSIS 


AND    ITS    COMPLICATIONS 


friTH  SPECIAL  REFERENCE  TO  DIAGNOSIS  AND  TREATMENT 
FOR   GENERAL  PRACTITIONERS  AND  STUDENTS 


SHERMAN  G.  BONNEY,  A.M.,  M.D. 

ICINE,   MEDICAL     DEPARTMENT 


CONSULTANT    TO    THE    DENVER     COUNTY    HOSPITAL 
DIRECTOR    OF    THE    NATIONAL    ASSOCIATION    FOR    THE    STUDY    AND   PREVENTION  OF  TUB 
MEMBER    OF    THE    AMERICAN    CLIMATOLOGICAL    ASSOCIATION 
EX-PRESIDENT    OF    THE    DENVER    CLINICAL    AND    PATHOLOGICAL    SOCIETY,  ETC 


IVITH  189  ORIGINAL  ILLUSTRATIONS,  INCLUDING 
20    IN    COLORS    AND    60    X-RAY    PHOTOGRAPHS 


PHILADELPHIA     AND     LONDON 

W.   B.   SAUNDERS   COMPANY 

1908 


Copyright,  1908,  by  W.  B.  Saunders  Company 


TO 

THE   MEMORY  OF   MY  FATHER 

Calvin  ]f.  Bonncvi,   riD.  2). 

WHO   FOR   NEARLY   HALF  A   CENTURY   SUSTAINED 
THE    HIGH    IDEALS   OF    THE    GENERAL    PRACTITIONER 


IQ. 
H 


PREFACE 


It  is  quite  impossible  to  present  an  exhaustive  treatise  upon  all 
phases  of  pulmonary  tuberculosis,  and  in  submitting  this  volume  for 
the  criticism  of  reviewers,  I  have  no  apology  to  make  for  its  limitations 
and  imperfections.  All  physicians  who  have  had  a  large  experience 
in  the  management  of  pulmonary  invalids  are  forced  to  the  conclusion 
that  there  is  not  so  comprehensive  a  knowledge  of  the  disease  as  fully 
to  conserve  the  interests  of  society.  Despite  the  many  excellent  con- 
tributions upon  the  general  subject,  there  is  perhaps  a  justification  for 
publishing  the  following  pages,  which  embody  largely  the  results  of 
personal  experience.  This  book  is  not  designed  for  the  benefit  of 
skilled  specialists  in  the  treatment  of  pulmonary  affections,  but  for 
the  use  of  general  practitioners  whose  opportunities  for  clinical  study 
may  have  been  somewhat  limited.  Its  preparation,  conducted  during 
the  course  of  an  active  practice,  has  consumed  a  vast  amount  of 
time,  and  the  work  has  been  delayed  by  many  unavoidable  interrup- 
tions. 

It  has  been  my  desire  that  the  book  should  be  devoted  essentially  to 
the  clinical  aspects  of  pulmonary  tuberculosis,  and  an  effort  has,  therefore, 
been  made  to  emphasize  practical  considerations.  To  this  end  I  have 
endeavored,  through  the  various  lights  and  shadows  of  every-day  obser- 
vation, to  portray  different  phases  of  the  disease  in  such  a  manner  as  to  ac- 
centuate important  points  without  obscuring  other  detail.  In  the  interests 
of  clearness  and  force,  brief  illustrative  cases  are  introduced  in  the  text, 
but  comparatively  little  space  is  devoted  to  the  consideration  of  alluring 
theories.  In  presenting  certain  aspects  of  pulmonary  tuberculosis  it 
has  been  necessary  to  make  use  of  the  contributions  of  innumerable 
scientific  workers.  To  those  whose  labors  in  the  realm  of  experimental 
research,  histologic  study,  or  clinical  observation  have  added  to  the 
sum-total  of  our  present  knowledge,  I  have  endeavored  to  give  due 
credit  in  the  text.  If  suitable  recognition  has  not  been  accorded  in 
any  instance,  such  omission  is  purely  unintentional.  In  several  para- 
graphs relative  to  the  physiologic  effects  of  climate,  I  have  made  free 
use  of  material  contained  in  Huggard's  "Handbook  Upon  Climatic 
Treatment,"  and  wish  to  express  my  obligation. 

It  is  with  some  hesitation  that  I  venture,  in  the  last  chapter  of  the 
book,  to  report  my  clinical  observations  concerning  the  practical 
application  of  vaccine  therapy  to  cases  of  pulmonary  tuberculosis. 
Some  doubts  have  existed  in  my  mind  as  to  the  propriety  of  introducing 
more  than  passing  mention  of  this  phase  of  specific  medication.  It  is 
apparent  that  such  a  subject,  even  though  of  engrossing  interest  and 
probable  value,  must  be  adjudged  upon  the  basis  of  continuous  con- 
servative investigation.  While  it  is  recognized  that  errors  inevitably 
occur  in  the  interpretation  of  clinical  findings,  such  a  study  relative  to 
the  actual  efficiency  of  newer  therapeutic  measures  must  remain  an 
important  feature  of  scientific  progress.     The  evolution  of  complete 


24335 


knowledge  concerning  the  workings  of  the  complex  mechanism  of 
immunity  will  be  acquired  only  through  the  process  of  years.  It  may 
api>ear,  therefore,  somewhat  presumptuous  at  this  time  to  present 
clinical  observations  with  reference  to  a  feature  of  treatment  that  may 
be  subject  to  considerable  future  modification.  In  view,  however,  of 
an  instructive  experience  during  the  past  one  and  one-half  years  with 
the  bacterial  vaccines,  I  am  constrained  to  report  the  results  thus  far 
attained. 

Appreciative  thanks  are  rendered  to  many  private  patients  who 
have  granted  photographic  illustrations.  Grateful  acknowledgment 
is  made  to  Dr.  William  C.  Mitchell,  for  valuable  suggestions  with  refer- 
ence to  features  of  bacteriologic  interest;  to  Dr.  J.  A.  Wilder,  for 
reviewing  the  chapters  upon  Pathology;  to  Dr.  Howell  T.  Pershing,  for 
reading  the  text  upon  Miliary  Tuberculosis,  as  well  as  upon  the  Symptoms 
and  Course;  to  Dr.  Charles  A.  Powers,  Dr.  F.  L.  Dixon,  and  Dr.  George 
B.  Packard,  for  reviewing  portions  of  the  book  devoted  to  Surgical 
Complications;  to  Dr.  Robert  Levy,  for  reading  the  text  upon  Tuber- 
culosis of  the  Larynx  and  assistance  rendered  in  securing  photographs 
of  this  condition;  to  Dr.  J.  N.  Foster,  for  reviewing  the  chapter  upon 
Tuberculosis  of  the  Ear  and  Nose;  to  Dr.  H.  B.  Whitney,  for  reading  the 
text  relating  to  the  Physical  Signs;  to  my  assistant,  Dr.  E.  W.  Enier}-, 
for  very  useful  suggestions  in  connection  with  many  portions  of  the 
book,  and  to  Dr.  S.  B.  Childs,  for  valuable  aid  in  securing  the  x-ray 
pictures.  I  am  indebted  to  Mr.  Ira  D.  Cassidy  for  the  skill  displayed 
in  the  drawings  and  paintings,  to  Mr.  F.  O.  Stanley  and  Mr.  B.  S. 
Hopkins  for  their  interest  and  efficiency  in  connection  with  the  photo- 
graphic illustrations,  to  my  publishers  for  the  excellence  of  the  repro- 
ductions, and  to  my  secretary,  Miss  Nellie  Bryant,  for  aid  in  the  prepara- 
tion of  the  manuscript. 

S.  G.  BONNEY. 
Denver,  Colorado, 
July,  1908. 


CONTENTS 


PART    I 

PAGE 

Etiology  and  Pathologic  Anatomy 17-93 

SECTION   I 
General  Etiologic  Considerations 17-76 

CHAPTER  I 

Introduction 17-19 

Historic  Review. 

CHAPTER  II 

The  Tubercle  Bacillus 19-26 

Morphologic  Cliaracteristics — Staining  Metliods — Differentiation — 
Cultural  Characteristics — Vitality — Composition — Various  Types  of 
Tubercle  Bacilli:  Tlie  Human  Bacillus,  the  Bovine  Bacillus,  the 
Avian  Bacillus,  and  the  Bacillus  of  Fish  or  other  Cold-blooded  Animals. 

CHAPTER  III 

Relation  of  Human  and  Bovine  Bacilli 27-35 

Historic  Survey — Koch's  Doctrine — Results  of  E.xperiments — Clin- 
ical Study — Report  of  British  C'ommission — Recent  Investigations — 
Contradictory  Evidence — Morphologic  and  Cultural  Differences — 
Conclusions. 

CHAPTER  IV 

The  Congenital  Method  of  Infection 36-42 

Hereditary  Transmi.ssion — Entrance  of  tlip  P.iirilli  Tliroudi  the 
Medium  of  the  Spermatic  Fluid,  tlie  Ovum,  ami  iIm-  PImi.  ni.il  (ircula- 
tion — Pathologic  Evidence — E.xperimentatiuTi  in  Animals  ( 'linical 
Investigation — Latency  of  Infection — Tulicn-lc  iirpoMt  in  Inaccessi- 
ble Areas — Prevalence  of  Infection  Among  the  Very  ^  oung — Fre- 
quency of  Tuberculosis  Among  Children  of  Consumptive  Parents. 

CHAPTER  V 

Invasion  by  Way  of  the  Respiratory  Tract 43-50 

Modification  of  Former  Views  Regarding  the  Inhalation  Method  of 
Infection — Cornet's  Theory — Fliigge's  Investigation — Arguments  in 
Favor  of  Inhalation  Infection — The  Supposed  Frequency  of  Primary 
Lesions  in  the  Lung  in  Comparison  with  the  Intestinal  Tract — Animal 
Experimentation — Researches  of  Calmette  and  his  Followers — 
Localization  of  Tuberculous  Lesions — Prevalence  of  Consumption  in 
Prisons  and  Other  Institutions — The  Import  of  Tenement-house 
Investigation. 

CHAPTER  VI 

Invasion  Through  the  Digestive  Tract 51-54 

Invasion  W  Human  and  Bovine  Bacilli — Frequency  of  Primary 
Intestinal  Lesions — Experiments  of  Calmette.  Guerin,  and  Others — 
Behring's  Theory — Sources  of  Infection  by  Way  of  the  Alimentary 
Tract — Importance  of  tliis  Route  of  Invasion. 


Z  CONTENTS 

CHAPTER  VII 

PAGB 

Distribution  of  the  Bacilli 55-56 

Maimer  of  Dissemination  of  Human  and  Bovine  Bacilli. 

CHAPTER  VIII 


Prevalence  of  Tuberculosis 

Statistical  Observations — Economic  Considerati^ 


CHAPTER  IX 


Influence  of  Race 59-64 

The  Negro — The  American  Inilian — The  Irish — The  Swede — The 
Jew — The  American. 

CHAPTER  X 

Influence  of  Geographic  Position 65-66 

Consumption  Known  to  Occur  in  all  Regions — Conclusive  Evidence 
Regarding  Relative  Degree  of  Immunity  Conferred  Through  the  Influ- 
ence of  Altitude,  Dryness,  and  Sunshine. 

CHAPTER  XI 

To  Wh.\t  Extent  is  Consumption  Indigenous  in  Colorado? 66-71 

Erroneous    Views    Formerly    Entertained — Statistical    Inquiry    Con- 
cerning the  Alleged  Increase  of  Indigenous  Tuberculosis  in  Colorado —  . 
Statements   to  this  Effect   have  been  Shown  to  be  Inspired  by  an 
Unwarranted  Assumption  as  to  Actual  Facts. 

CHAPTER  XII 

General  Conditions  Influencing   Infection  After  Exposure  to  the 

Tubercle  Bacillus 72-75 

Heredity — Environment — Social     Conditions — Occupation — Previous 
-Virulence  of  Bacilli. 


Pathologic  Anatomy 76-93 

CHAPTER  XIII 
General  Considerations 76-78 


CHAPTER  XIV 

Structure     o 
Format  i-ii 
tion    \.- 

Hyperp 

lous    I'n.r,  -- 

.f       E1.TM( 

r,.llii:,|.    1 

■ntary      Tul.crfle- Do' 

■1      1     .  .■  •■  ..:,     l; 

'•     ■•:     1       ■;.      1  '^      ■    ■ 

hl.liy      lllll;!liilii:ilniy      1 

CHAPTER  XV 

oinuent  of  Tubercle 
we  Processes,  Coagula- 
live  Connective-tissue 
I'xtension  of  Tubercu- 


Gross  Appearances 

Essential  Differences  in  the  Pathologic  Lesions  Despite  Histologic 
Identity  of  the  Various  Tuberculous  Processes — Miliary  Tuberculosis-^ 
Acute  Pneumonic  Phthisis  (Lobar) — Acute  Pneumonic  Phthisis 
(Lobular) — Chronic  Caseofibroid  Phthisis — Chronic  Fibroid  Phthisis^ 
Site  of  Primary  Involvement. 


CONTENTS  3 

PART    II 

PAGE 

Symptomatology  and  Course,  Varieties,  and  Termination  94-153 


CHAPTER  XVI 

Method  of  Onset 

Acute  and  Non-acute — Acute  Onset  Exhibited  in  Acute  Pneumonic 
Phtliisis,  Acute  Bronchopneumonic  Phthisis  and  Miliary  Tubercu- 
losis of  the  Pneumonic  Type — Acute  Onset  Characterized  by  Initial 
Pulmonary  Hemorrhage,  Pleurisy,  Septic  Manifestations,  Severe 
Bronchitis,  and  Influenza — Non-acute  Onset  Developing  as  a  Latent 
Infection,  the  Anemic  Variety,  the  Dyspeptic  Type,  Initial  Laryn- 
geal Symptoms,  and  Following  Tuberculous  Cervical  Glands — 
Pleurisy,  Pneumonia,  Typhoid  Fever,  Measles,  and  Other  Infectious 


CHAPTER  XVII 

Cough  and  Expectoration 101-105 

Varieties  of  Cough — Individual  Idiosyncrasies — Relation  of  Cough 
to  External  Conditions — Differences  in  Quantity,  Gross  Appear- 
ance, Manner  of  Expulsion,  and  Composition  of  Expectoration. 

CHAPTER  XVIII 

Pain,  Hoarseness,  and  Dyspnea 106-110 

Causes  and  Types  of  Pain — Alterations  of  Voice — Varieties  of 
Dyspnea. 

CHAPTER  XIX 

Fever 111-114 

Significance  of  Fever — Origin  and  Variability — Clinical  Types. 

CHAPTER  XX 

Emaciation  and  Local  Objective  Symptoms 115-119 

Relation  of  Body  Weight  to  the  Activity  of  the  Tuberculous 
Process — Relation  of  Nutrition  to  Fever — Changes  in  Fingers 
and  Skin. 

CHAPTER  XXI 

CiRCtiL.\TORY  Disturbances 120-122 

Changes  o 
tion  of  Ar 
of  Lungs. 


Changes  of  Pulse — Frequent  Acceleration  in  Early  Stages — Diminu- 
tion of  Arterial  Tension — Cardiac  Weakness — Endocarditis — Edema 


CHAPTER  XXII 

Pulmonary  Hemorrhage 123-130 

Frequency — Causes  and  Types — Immediate  and  Remote  Effects — 
Influence  of  Climate  upon  Hemoptysis. 

CHAPTER  XXIII 

Symptoms  Referable  to  the  Digestive  Apparatus 131-134 

Stomach   Disturbances — Organic    Changes    and    Psychoneuroses— 
Intestinal  Symptoms— Diarrhea. 


CHAPTER  XXIV 

FAGE 

Symptoms  Referable  to  the  Mind  and  Nervous  System 135-141 

Incorrect  Notions  Concerning  Essential  Traits  of  Character 
Common  to  Consumptives — Impossibility  of  Definite  Generaliza- 
tions— Individual  Temperamental  Peculiarities — Occasional  Per- 
verted Mentality — Insomnia — Nervous  Energy. 

CHAPTER  XXV 

Symptoms  Referable  to  the  Genito-urinary  Tract 142-144 

Albuminuria — Casts — Amyloid — Acute  Nephritis — Sexual  Desire 

SECTION    II 

Course,  Varieties,  and  Termination 145-153 

CHAPTER  XXVI 

The  Clinical  Course 145-146 

Differences  in  General  Type  and  Duration. 

CHAPTER  XXVII 

Special  Varieties 147-151 

Fibroid  Phthisis — Pneumonokoniosis  with  Clironic  Bronchitis — 
Emphysema — Fibrous  Tissue  Change,  Disturbance  of  Circulation 
and  Ultimate  Tubercle  Infection — Symptoms  and  Physical  Signs  of 
Preceding  Group  of  Chronic  Pathologic  Conditions. 

CHAPTER  XXVIII 

Termination 152-153 

Modes  of  Death. 


PART    III 

Physical  Signs 154-233 

Introduction. 


General  Physical  Signs 155-217 

CHAPTER  XXIX 

Inspection 155-173 

Rules  for  the  Practice  of  Inspection — Conditions  Independent  of 
the  Thorax  Nolcil  upMn  ln-|>irtion — Character  of  Respiration — 
Inspection  of  the  i  Im  -t  >i/r  and  Shape  of  the  Thorax — rnilateral 
Irregularities — Fn  -| ,i i  1 1 , .ly  Mi ivements — Litten's  Phenomenon — 
Cardiovascular  f 'haii;;'  >  I  liaiiges  in  the  Precordia  as  a  Whole — 
Changes  in  the  Apex  Impulse — Epigastric  Pulsation — Changes  in 
the  Neck. 

CHAPTER  XXX 

Palpation 174-176 

Confirmation  of  the  Results  of  Inspection — Vocal  Fremitus — 
Normal  Disparity  at  the  Apices — Palpable  Rhonchi  and  Friction- 
sounds. 


CHAPTER  XXXI 

PAGE 

Percussion 177-190 

Resonant  and  Non-resonant  Sounds — Analytic  Characteristics  of 
Resonance,  Intensity,  Pitch,  and  Quality — Rules  for  the  Practice  of 
Percussion:  Rules  for  the  Patient,  Rules  for  the  Physician,  Position 
of  Pleximeter  P'inger,  Manner  of  Dealing  the  Blow — Position  of 
Examiner— Percussion  of  the  Normal  Chest:  Regional  Differences, 
Disparity  at  the  Apices,  Percussion  Boundaries,  Areas  of  Cardiac 
Dulness  and  Flatness.  Percussion  in  the  Midst  of  Abnormal  States: 
Absence  of  Resonance  or  Flatness,  ("hanges  in  Intensity,  Changes  in 
Quality — Tympanitic,  Amphoric,  and  Cracked-pot  Resonance — 
Changes  in  Pitch — Wintrich's  Change  of  Pitch  and  Gerhardt's 
Change  of  Pitch. 

CHAPTER  XXXII 

Auscultation 191-217 

Manner  of  Auscultation — The  Stethoscope — Rules  for  the  Per- 
formance of  Auscultation:  Rules  for  the  Patient,  Rules  for  the 
Examiner — Auscultation  of  the  Normal  Chest:  Respiratory  Sounds, 
Vesicular  Respiration  as  Compared  with  Breath-sounds  Heard 
over  the  Larynx,  Regional  Ditferences,  Normal  Disparity  Between 
the  Two  Apices,  Normal  Voice-sounds,  Vocal  Resonance  Over  the 
Larynx  or  Trachea,  Vocal  Resonance  Over  Normal  Lung,  the 
Whispered  Voice— Auscultation  in  the  Midst  of  Pathologic  Con- 
ditions: Modifications  of  Normal  Respiratory  Sounds,  Changes  in 
Intensity,  Diminution  of  Intensity,  Emphysematous  Type  of 
Breathing,  Increased  Intensity  of  Breath-sounds,  Changes  in  Pitch 
and  Quality,  Bronchial  Respiration,  Bronchovesicular  Respiration, 
Cavernous  Breathing,  Amphoric  Respiration,  Metamorphosing 
Respiration,  Changes  in  Duration,  Changes  in  Rhythm,  RAles, 
Tracheal  Rdles,  Moist  Bronchial  RAles,  Dry  Bronchial  Rdles,  Vesic- 
ular Rales,  Cavernous  Rales,  Pleural  Rfiles,  Succussion  Sounds, 
Metallic  Tinkling.  Indeterminate  Rales — Modifications  of  the  Normal 
Spoken  and  Whispered  Voice  in  Disease:  Changes  in  Intensity, 
Changes  in  Pitch  and  Quality,  Bronchophony,  Egophony,  Pectorilo- 
quy- 

SECTION  II 

Physical  Signs  of  Pulmonary  Tuberculosis 218-233 

CHAPTER  XXXIII 
General  Considerations 218-219 

CHAPTER  XXXIV 

Early  Cases 219-222 

The  Especial  Importance  of  Auscultatory  Signs — The  Significance 
of  Localized  Unilateral  Rales — Value  of  Cough  in  the  Detection  of 
Fine  Rales  During  the  Ensuing  Inspiration. 

CHAPTER  XXXV 

Cases  With  Moderate  Involvement 223-228 

Visual  Changes — Irregularity  of  Contour— Arhythmic  Respiratory 
Movements— Evidences  Obtained  upon  Palpation— Percussion 
Signs — Deviations  from  Normal  Percussion  Outlines. 

CHAPTER  XXXVI 

Advanced  Cases 229-233 

Striking  Combination  of  Physical  Signs  Noted  upon  Inspection, 
Palpation,  Percussion,  and  Auscultation. 


6  CONTENTS 

PART    IV 

PAGE 

Diagnosis  and  Prognosis 234-323 

SECTION  I 
Diagnosis 234-298 

CHAPTER  XXXVII 
Preliminary  Considerations 234-235 

CHAPTER  XXXVIII 

Provisional  DL\t;.NiisTic  Factors 236-239 

Family  Hi>tury — Acquired  Predisposition — Opportunities  for  Infec- 
tion—Prt-viuus  Di.seusos. 

CHAPTER  XXXIX 

Present  Condition 240-245 

Existing  Constitutional  Disturbances — Cough — Loss  of  Weight — 
Fever — Acceleration  of  Pulse— Exploration  of  Chest— Results  of 
Physical  Examination — Sputum  Examinations. 

CHAPTER  XL 

Special  Aids  to  Dl^gnosis 246-293 

The  Tuberculin  Test — The  Ophthalmotuberculin  Reaction — Experi- 
ments upon  Animals — The  Rontgen  Rays. 

CHAPTER  XLI 

Differential  Di.\gnosis 294-298 

Importance  of  Laboratory  Findings — "Miner's  Phthisis  " — Chronic 
Influenza — Pulmonary  Syphilis — The  Significance  of  Pulmonary 
Hemorrhage — Reports  of  Cases. 

SECTION   II 
Prognosis 299-323 

CHAPTER  XLII 
General  Considerations 299-300 

CHAPTER  XLIII 

Factors  Pertaining  to  the  Individual 300-311 

Age — Sex — Race — Family  History — Individual  Resistance — Occu- 
pation— Temperament,  Disposition.  Intelligence,  and  Character 
— Financial  Condition — Social  Environment — Personal  Equation — 
Change  of  Surroundings  and  Climate 

CHAPTER  XLIV 

Considerations  Pertaining  to  the  Disease 312-323 

Historj'  of  Present  Illness — Physical  Signs — Extent  of  Pathologic 
Change — Activity  of  Infection— Evidences  of  Immunity — Character 
of  Systemic  Disturbances — Possibility  of  Arrest  Offered  Even  to 
Advanced  Cases — Reports  of  Dlustrative  Cases. 


CONTENTS  7 

PART   V 

PAGE 

Complications 324-559 

Introduction. 

SECTION   1 

Acute  Miliary  Tuberculosis ,. 324-346 

CHAPTER  XLV 

General  Considerations 324-328 

Historic  Review — Etiology — Frequency — Varieties. 

CHAPTER  XLVI 

The  PNEtTMONic  Type 329-330 

Clinical  Manifestations. 

CHAPTER  XLVII 

The  Typhoid  Type 331-334 

Method  of  Onset — Subjective  Symptoms — Physical  Signs — Differ- 
ential Diagnosis. 

CH.A.PTER  XLVIII 

The  Meningeal  Form 335-346 

Pathogenesis — Pathologic  Change — Symptoms  in  Adults — Symp- 
toms in  Children  from  Two  to  Six  Years  of  Age — Symptoms  in 
Infants — Differential  Diagnosis — Reports  of  Cases — Treatment. 

SECTION   II 

Tuberculosis  of  the  Pleura 347-394 

Introduction. 

CHAPTER  XLIX 

Etiology  and  Pathology  of  Tuberculous  Pleurisies 348-352 

Secondary  Nature  of  the  Tuberculous  Infection — Frequency — For- 
mer DifiicuUies  of  Diagnosis — Inflammatory  Changes  With  or  With- 
out Effusion — Character  of  Effusion. 

CHAPTER  L 

Symptomatology  of  Tuberculous  Pleurisies 353-357 

Subjective  Symptoms — Physical  Signs — Outlines  of  Percussion  Dul- 


CHAPTER  LI 

Displacement  of  Organs 358-362 

Frequency  of  Cardiac  Displacement  Among  Pulmonary  Invalids — 
Illustrative  Cases. 

CHAPTER  LII 

Dlagnosis  and  Prognosis  of  Pleurisies  in  Pulmonary  Invalids  ....   363-365 
Importance  of  Detailed  Physical  E.xamination. 


CHAPTER  LIII 

Treatment  of  Serous  Effusion 366-372 

General  Measures — Absorption  of  Pleural  Effusion — Indications 
and  Contraindications  for  Aspiration — Rules  for  the  Performance 
of  Aspiration. 

CHAPTER  LIV 

Empyema 373-382 

Clinical  Manifestations — Exploratory'  Puncture — Methods  of  Treat- 
ment— Reports  of  Cases. 

CHAPTER  LV 

Pneumothor.ix 383-388 

Subjective  Symptoms  and  Physical  Signs — Diagnosis — Clinical 
Varieties — Prognosis — Treatment. 

CHAPTER  LVI 

Pneumopyothorax 389-394 

Physical  Signs — Prognosis — Treatment. 

SECTION    ill 
Tuberculosis  of  Pericardium  and  Peritoneum 395-411 


CHAPTER  LVir 

Tuberculosis  of  the  Pericardium 395-403 

Etiologic  and  Pathologic  Data — Varieties — Symptoms  of  Peri- 
cardial Effusion — Physical  Signs — Course  and  Prognosis — 
Diagnosis — Treatment  of  Effusion — Adherent  Pericardium. 

CHAPTER  LVIII 

Tuberculosis  of  the  Peritoneum 404-411 

Etiologic  Relations — Symptoms — Physical  Examination — Diagnosis 
— Prognosis — Treatment. 


SECTION    IV 
Glandular  Tuberculosis 412-439 

CHAPTER  LIX 

Pathogenesis  of  Glandular  Infection 412-417 

Distribution  of  Bacilli  Through  Lymphatic  Channels— Drainage 
of  Tributary  .\reas — Role  of  the  Tonsils  and  Adenoids  in  Affording 
Ports  of  I'ntry — Permeability  of  Intestinal  Wall — Frequency  of 
Glandular  Tuberculosis  in  Children— Statistical  Observations. 

CHAPTER  LX 

Tuberculosis  of  the  Cervical  Gl.\nds 418-421 

Clinical  Manifestations — Diagnosis. 


CONTENTS  9 

CHAPTER  LXI 

PAGE 

Tuberculosis  op  Mediastinal  and  Mesenteric  Glands 422-428 

Symptoms  of  Tuberculous  Enlargement  of  Tracheobronchial  Glands 
— Physical  Signs  of  Tracheal  Compression — Physical  Signs  of  Bron- 
chial Compression — Diagnosis  of  Glandular  Enlargement — Illustra- 
tive Case — Tabes  Mesenterica. 


CHAPTER  LXII 

Treatment  of  Glandular  Tuberculosis 429-439 

General  Treatment — Hygienic  Measures — Change  of  Environ- 
ment— Recreative  Existence  in  Open  Air — Seashore  Hospitals — 
Change  to  the  Country  or  Mountains — Review  of  the  Supposed 
Efficacy  of  the  Kingly  Touch — Medicinal  Treatment — Specific  Medi- 
cation. Local  Efforts:  Non-operative  Measures  Embracing  Coun- 
terirritation,  Massage,  Electrolysis,  x-Ray.  Surgical  Procedures: 
Including  Aspiration,  Interstitial  Injections,  Incision,  and  Drainage 
With  or  Without  Curetment  or  Cauterization,  Complete  Excision. 
Illustrative  Case. 


SECTION   V 
Tuberculosis  of  Bones  and  Joints 440-461 


CHAPTER  LXIII 

Etiologic  and  Pathologic  Considerations 440-443 

Statistical    Observations — Frequency   of   Bone   and   Joint   Lesions 


in  Early  Childhood — Influence  of  Trauma. 


CHAPTER  LXV 

Clinical  Manifeistations  of  Bone  and  Joint  Tuberculosis 444-456 

Early  Symptoms — General  Prognostic  Features — Caries  of  Spine: 
Symptoms  and  Diagnosis,  Illustrative  Case.  Tuberculosis  of  Hip- 
joint:  Symptoms,  Diagnosis.  Tuberculosis  of  Knee-joint:  Symp- 
toms. 

CHAPTER  LXIV 

Treatment  of  Tuberculosis  of  Bones  and  Joints 457-461 

General  Hygienic  Management — Constitutional  Treatment — Local 
Management — Non-operative  Measures — Mechanical  Contrivances 
—The  Bier  Treatment— Surgical  Procedures. 


SECTION    VI 
Tuberculosis  op  the  Alimentary  Tract 462- 


CHAPTER  LXVI 


Etiologic  and  Anatomic  Factors  . 


Tuberculosis  of  the  Mouth,  Tongue,  Gums,  Tonsils,  Esophagus,  and 
Stomach. 


10  CONTENTS 

CHAPTER  LXVII 

PAGE 

Tuberculosis  of  the  Intestine 466-470 

Primary  Lesions  of  the  Intestine — Secondary  Lesions — Statistical 
Observations — Pathogenesis — The  Ulcerative  Type  of  Intestinal 
Tuberculosis — The   Hyperplastic    Type — Surgical    Procedures. 

CHAPTER  LXVIII 

Tuberculosis  of  the  Appendix 471-483 

Primary  Lesions — The  LHcerative  Tj^dc — The  Hyperplastic  Type — 
Clinical  Symptoms — Principles  of  Management — Appendicitis 
Among  Phthisical  Patients — Personal  Observations — Illustrative 
Cases. 

CHAPTER  LXIX 

Rectal  Fistul.\ 484-486 

Varieties — Management. 


SECTION   VII 

Tuberculosis  of  the  Genito-urinary  Tract 487-512 

CHAPTER  LXX 

General  Etiologic  Consider.^^tions 487-490 

Primary    and    Secondarj-    Infection — Direction    of    Bacillary  Dis- 
semination— More  Frequent  Sites  of  Infection — Statistical  Data. 

CHAPTER  LXXI 

Tuberculosis  of  the  Ividney 490-499 

Pathology — Clinical  Symptoms — Increased  Frequency  of  Urina- 
tion— Change  in  Character  of  Urine — Pain  and  Tenderness  in  Region 
of  the  ICidney — The  General  Health — Diagnosis — Tubercle  Bacilli 
in  the  Urine — Cystoscopic  Examination  of  the  Bladder — jr-Ray- 
■        of  the   Ui'  -..,..         •       . 


Segregation  of  the  Urine  or  Ureteral  Catheterization — Excretory- 
Capacity  of  Each  Ividney — Crj'oscopy — Treatment:  Hygienic, 
PaUiative,  Operative  Measures,  i.  e. ,  Xephrotomy,  Nephrectomy. 

CHAPTER  LXX  1 1 


Tuberculosis  op  the  Bladder 499-503 

Pathologic  Appearance — Symptoms  and  Diagnosis — Treatment — 
Cystotomy — Hlustrative  Case. 

CHAPTER  LXXIII 

Tuberculosis  of  the  Prostate  and  Seminal  Vesicles 504-506 

Frequency — Symptoms — Treatment. 

CHAPTER  LXXIV 

Tuberculosis  of  the  Epididymis  .vnd  Testes 506-510 

Pathologic  Change — Clinical  Symptoms — Diagnosis — Pro^osis — 
Management — Indications  for  Operation — Character  of  Surgical 
Interference — Illustrative  Cases. 

CHAPTER  LXXV 
Tuberculosis  of  the  Fallopian  Tubes,  Uterus,  and  Adjacent  Struc- 


CONTENTS  11 

SECTION   VIII 

PAGE 

Tuberculosis  of  the  Skin  and  Upper  Respiratory  Tract 513-540 

CHAPTER  LXXVI 

Tuberculosis  of  the  Skin 513-524 

Role  of  the  Skin  as  a  Channel  for  Tuberculous  Infection — Experi- 
mental Investigation — Clinical  Observations — The  Usual  Innocuous 
Character  of  Cutaneous  Infections — Origin  of  Tuberculous  Lesions — 
The  Contagion  of  Tuberculous  Meat — Tuberculous  Processes  Follow- 
ing Postmortem  Examinations — Accidental  Infection  Incident  to 
Close  Contact  with  Infectious  Sputum — Animal  Experimentation — 
Statistical  Observations — Differences  of  Histologic  Structure — 
Clinical  Varieties  of  Tuberculous  Lesions — The  Verrucous  Type — 
The  Necrogenic  Wart— The  Ulcerative  Variety— The  Scrofulous 
Type— Lupus  Vulgaris— Differential  Diagnosis  from  Syphilis- 
Prognosis  and  Management  of  Lupus. 

CHAPTER  LXXVII 

Tuberculosis  of  the  Larynx 524-535 

Etiology — Occasional  Primary  Infection — Illustrative  Case — Path- 
ologic Conditions — Subjective  Symptoms — Local  Appearances — 
Prognosis — General  Principles  of  Management. 


CHAPTER  LXXVIII 

Tuberculosis  op  the  Ear  and  Nose 535-540 

Etiologic  and  Anatomic  Data — Clinical  Manifestations — Occasional 
Infection  of  the  Eye. 

SECTION   IX 

Non-tuberculous  Conditions 541-559 

CHAPTER  LXXIX 

Mixed  Infection 541-549 

Varieties  of  Microorganisms — Modifications  of  Clinical  Course — 
Nephritic  Disturbances — Constitutional  Disturbances,  as  Fever, 
Chills,  Sweats,  General  Prostration — Detection  of  Microorganisms — 
Prognosis  of  Mixed  Infection — Management — Most  Complete  Inter- 
pretation of  the  Rest  Treatment — The  Employment  of  Bacterial 
Vaccines. 

CHAPTER  LXXX 

Pregnancy 549-554 

Influence  upon  the  Clinical  Course  of  Pulmonary  Tuberculosis — 
Its  Deleterious  Effect  not  Invariable — Illustrative  Cases — Indica- 
tions and  Contraindications  for  Interference. 

CHAPTER  LXXXI 

Syphilis 555-559 

Frequent  Coexistence  of  Syphilis  and  Tuberculosis — Influence 
of  Syphilis  upon  Vulnerability  of  Tissues  to  Future  Tuberculous 
Infection — Effect  of  Syphilis  upon  the  Course  of  a  Previously 
Acquired  Tuberculosis— The  Modifying  Action  of  Tuberculosis  upon 
Syphilitic  Infections  of  Remote  and  Recent  Origin — Possibilities 
of  Error  in  Differential  Diagnosis. 


12  CONTENTS 

PART    VI 

Prophylaxis,  General  Treatment,  and   Specific  Treat- 
ment     560-762 


SECTION   1 
Prophylaxis 560-61 1 


CH.\PTER  LXXXII 

Reciprocal  Relations  of  Consumptives  and  Society 560-565 

General  Principles  Governing  Systematic  Prophylaxis — Funda- 
mental Data  Pertaining  to  the  Communicability  of  Consumption — 
An  Imperative  Obligation  to  Enforce  all  Rational  Methods  of  Pre- 
vention— Necessity  for  a  Far-reaching  System  of  Education  and 
Control — Wisdom  of  Conservatism  in  Administrative  Supervision — 
The  Curability  of  Consumption — Tlie  Demand  for  Practical  Aid 
Rendered  to  the  Indigent  Consumptive  upon  Economic,  Human- 
itarian, and  Prophylactic  Grounds — The  Need  for  a  Concerted  Cam- 
paign. 

CHAPTER  LXXXIII 

Compulsory  Notification  and  Registration 566-571 

Effectiveness  of  Notification  Dependent  upon  Completeness  of 
Execution — Value  of  an  Awakened  Pubhc  Sentiment — The  Example 
of  New  York— The  Attitude  of  England  toward  Compulsory  Notifi- 
cation— Scotland,  Ireland,  Denmark,  Australia,  Roumania,  Norway, 
Holland,  Switzerland,  Belgium,  Germany,  France — The  Status  of 
Compulsory  Registration  in  the  United  States. 


CHAPTER  LXXXIV 

The  Supervision  and  Education  of  the  Consumptive 

The  Primary  Necessity  of  Instructive  Appeals  to  the  Invalid— 
The  Obligation  of  the  Consumptive  to  his  Fellows— Responsible 
Instruction  Emanating  from  a  Duly  Authorized  Source — Educa- 
tional Literature— Periodic  Visits— Features  of  Individual  Prophy- 
laxis— Disposal  of  Sputum — Hygiene  of  tlie  Sick-room. 


CHAPTER  LXXXV 

The  Extension  of  Material  Aid  According  to  the  Varying  Needs 

AND  Requirements  of  Differing  Classes 57 

The  Obligation  to  Render  Substantial  Assistance  to  Consumptives 
— Practical  Aid  for  tliose  Confined  to  their  Homes— Institutions  for 
Indigent  Consumptives — Sanatori\im  Care  Demanded  for  those  who 
are  Hopelessly  111  and  Impoverished,  the  \'icious  Refusing  to  Con- 
form to  Estafelislied  Rules  and  the  Consumptive  Poor  Offering,  with 
Suitable  Assistance,  a  Reasonable  Prospect  of  Recoverj' — The  Scope 
of  State  Sanatoria— Industrial  Facilities  for  the  Inmates  of  tliese 
Institutions— The  Influence  of  State  Sanatoria  upon  Neighboring 
Communities  and  Surrounding  Property— The  Tuberculous  Dis- 
pensary— ^The  Day  Resort — Social  Service  Bureaus. 


CONTENTS  13 

CHAPTER  LXXXVI 

PAGE 

The  Dissemination,  to  the  General  Public,  through  the  Medium  of 
Various  Channels,  op  Authentic  Official  Information  Regarding 

THE  Prevention  of  Consumption 586-595 

Education  of  the  General  Public — Unity  of  Purpose  and  Harmony 
of  Action  Important  Considerations — Tlie  Scope  of  Local  Anti- 
tuberculosis Societies — The  Necessity  of  Aggressive  Initiative, 
Tactfulness,  and  Enthusiastic  Devotion  to  Duty  of  Executive 
Officers — The  Work  of  The  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis — Instruction  Imparted  to  the  People 
through  tlie  Medium  of  the  School-room — Publications — The 
Lecture  Platform — Exhibitions — The  Family  Physician. 

CHAPTER  LXXXVII 

What  the  Public  Should  Know 595-601 

The  Procreation  of  Predisposed  Infants — The  Marriage  of  Tuber- 
culous Individuals — The  Dangers  of  Postnatal  Infection — The 
Character  and  Preparation  of  the  Food — The  Frequent  Contamina- 
tion of  Milk  liy  Various  Bacteria — The  Proximity  to  a  Consumptive 
within  the  Household — Precautionary  Rules — Prophylaxis  in  the 
School-room — The  Importance  of  Proper  Nutrition — Class  Breathing 
Exercises — Employment  of  Child  Labor — Effect  of  Alcohol — Social 
Indulgence — Abnormal  Athletic  Accomplishments. 

CHAPTER  LXXXVIII 

Administrative  Control 601-61 1 

The  Suppression  of  Promiscuous  Expectoration  in  Public  Places — 
The  Regulation  of  Schools — Inspection  of  Food-supply — Control 
of  Patent  Medicine  Evil-and  Restriction  of  Medical  Practice — The 
Demand  for  Hygienic  Construction  and  Sanitary  Supervision  of 
Public  Buildings,  Conveyances,  Factories,  Tenement  Houses,  and 
Commercial  Establisliments — Cooperation  of  Operatives — Financial 
Assistance  to  Employees  when  Incapacitated  by  Disease — Compul- 
sory Insiu-ance  for  \\'orkiiig  Peojile. 

SECTION    II 


CHAPTER  LXXXIX 

General  Considerations 612-615 

The  Responsible  Obligation  for  the  Employment  of  Rational 
Conservative  Measures— Fanciful  Theories  of  Past  Generations— 
An  Array  of  Methods  and  Remedies  Vaunted  Even  in  Recent 
Years— Necessity  for  a  Careful  Estimate  of  the  lm])ortance  Attach- 
ing to  the  Many  Phases  of  Therapeutic  Effort— Principles  of 
Management. 

CHAPTER  XC 

-Regard  for  Infinite  Detail 615-619 

A  Careful  Preliminary  Investigation  of  all  Phases  of  the  Disease, 
Physical,  Symptomatic,  and  Historic — Diligent  Study  of  all  Factors 
Pertaining  to  the  Patient.  Teinpprampnt.Tl.  Fin.iiiVial,  Dimipstic, 
Social— Necessity  for  Continual  Stu.ly  Mil. I  Mel  \i,Lnl-m.'..  i;,.L',-ird- 
ing  the  Special  Requirement  <  in  i;;i(li  (':i-r  linplirit  (  )l»  ,lii  ni  r  lo 
Detailed  Instructions— The  Duly  ..i  il,,.  i'liy-iri;iii  \aryiiii;  «iili  the 
Inherent  Requirements  of  the  Individual— Tlie  De.sirability  of 
Emphatic  Unequi\'ocal  Instructions. 


14  CONTENTS 

CHAPTER  XCI 

PAGE 

Adjustment  of  Physical  and  Nervous  Effort 619-625 

Conservation  of  Energy  the  Watchword  for  Consumptives — 
Avoidance  of  Fatigue  from  any  Cause,  Physical,  Nervous,  or  Mental — 
Open  Air  often  Subordinate  to  Complete  Rest — Physical  Exertion 
Absohitely  Forbidden  to  Advanced  Consumptives — Fever  Sug- 
gesting a  Mandatory  Insistence  upon  Absolute  Rest — Forms  of 
Exercise  to  be  Selected  with  the  Greatest  Care — Recreation  should 
be  Combined  with  Exercise — Indications  and  Contraindications  for 
Pulmonary  Gymnastics. 

CHAPTER  XCII 

Enforcement  op  an  Open-air  Existence 626-639 

Fresh  Air  an  Essential  Factor — The  Inhalation  of  Pure  Air  not  the 
Sole  Desideratum — The  Necessity  for  an  Appropriate  Environment — 
Provision  for  Securing  the  Maximum  Amount  of  Fresh  Air — 
Arrangements  for  Comfort  and  Shelter — Clothing — Bed-clothing — 
Desirable  Features  of  an  Outdoor  Abode — Porch  Accommodations — 
Tent  Life — Wooden  Shelters — Sleeping  Out-of-doors. 

CHAPTER  XCIII 

Regul.\tion  of  Diet 639-651 

The  Importance  of  a  Gain  in  Nutrition  through  Improvement  of 
Digestion  and  Assimilation — The  Attainment  of  such  a  Standard  of 
Nutrition  as  will  Produce  the  Greatest  Powers  of  Resistance — 
Differences  of  Opinion  as  to  Amount  and  Character  of  Food  Neces- 
sary ti>  Piiimote  Nutrition  to  Best  Advantage — Limitations  to  an 
1!  il.  I  ii  -y^tem  of  Superalimentation — Futility  of  an  Arbitrary 
^  Mittetics — Caloric  Values — Delusive  Theories  Regarding 

I  ■    :i  ;   I'unctional  Demands — Careful  Inquiry  as  to  Digestive 

•  aj  .it:'.\  lustes  of  the  Patient — Variety  and  Character  of  Food — 
Maimer  ot  Cooking — Dietary  Direction— Outline  of  Meals  Appro- 
priate for  Pulmonary  Invalids — Extra  Nourishment — Alcohol — 
Contraindications  for  Excessive  Feeding — Fever — Disorders  of 
Digestion — Organic  Changes — Psychoneuroses. 

CHAPTER  XCIV 

Scope  of  the  San.^^torium  as  a  THERAPErric  Factor 651-667 

A  Suitable  Regime  an  Essential  Prerequisite  for  Successful  Man- 
agement— Unusual  Facilities  for  Autocratic  Supervision  Afforded 
in  Institutions — X  Perfected  System  of  Regimen  Permissible 
Outside  .Sanatoria — Practical  Utility  of  Sanatorium  Control  for 
Carefully  Selected. Cases — Summary  Recourse  to  Complete  Institu- 
tional Rfsime  Prcjiirlit-inl  to  the  Interests  of  Some  Invalids — 
Personnl  Kpi  ••■  -  ''  •'  Patient  and  Physician— Character  of 
Cases   A  liiii  !is — The  P.sychic  Element — Environ- 

ment   :iihl     I  Hidings — Economic  and   Educational 

Phases  (.1  I  111   -  .  .1    ■.  .-nient. 

CHAPTER  XCV 

The  Role  of  Climate  in  the  Tre.vtment  of  Pulmonary  Tuberculo- 
sis     667-701 

The  Value  of  Climate  Recognized  from  the  Earliest  Days  of 
Medicine  and  Attested  by  Irrefutable  Clinical  Observation — A 
Recent  Tendency  to  Renounce  the  Therapeutic  Efficacy  of  Cli- 
mate— Affirmative  Evidence — Definition  and  General  Considerations 
of  Climate — ("hemic  and  Bacteriologic  Purity  of  the  Air — Physi- 
ologic Considerations — The  Potentialities  of  Climate  Referable"  to 
the  Influence  of  Surrounding  Air  Medium  upon  Metabolism — The 
Influence  of  Climate  upon  Nutrition  Largely  Dependent  upon  the 


Degree  of  Its  Heat-abstracting  Capabilities — Influence  of  Tempera- 
ture, Humidity,  Wind  Movement — Variability  of  Heat-dissipation — 
Diminished  Atmospheric  Pressure — Influence  of  Altitude  upon  Red 
Blood-corpuscles,  Blood-pressure,  Respiration,  Nervous  System — 
Necessity  for  Individualization — Clinical  Testimony  Regarding  the 
Value  of  Climate — Inconsistency  of  Opponents — Cases  Appropriate 
for  Climatic  Change — Four  Distinct  Classes — Cases  Inappropriate 
for  Climatic  Change  in  General — Considerations  Relative  to  Climatic 
Selection — Importance  of  a  Discriminating  Choice  of  Climate 
According  to  the  Physiologic  Adaptation  of  the  Individual — Contra- 
indications for  Residence  in  High  Altitudes — Cases  Suited  to  Low 
Temperature  with  Varying  Degrees  of  Moisture — Popular  Localities. 

CHAPTER  XCVI 

Treatment  op  Special  Symptoms 701-7 1 1 

Cough — Extraordinary  Differences  of  Character — Divergence  of 
Therapeutic  Indications — Local  Causative  Factors — General  Con- 
stitutional Disturbances — Detailed  Hygienic  Measures — Subjective 
Control  on  the  Part  of  the  Individual — Digestive  Disorders:  Dietetic 
and  Medicinal  Management — Organic  Disturbances:  Functional 
Neuroses — Night-sweats:  Hygienic  Measures — Insomnia:  Attention 
to  Predisposing  Causes — Cardiac  Weakness. 

CHAPTER  XCVII 

Treatment  of  Pulmonary  Hemorrhage 711-723 

General  Considerations — Modifications  of  Treatment  According  to 
Intelligent  Interpretation  of  the  Significance  of  Clinical  Manifesta- 
tions— Therapeutic  Management — The  Initial  Directing  Influence  of 
the  Physician — Attention  to  Vitally  Important  Details  of  Manage- 
ment and  Environment — Rational  Employment  of  Selected  Drugs — 
Management  of  Aspiration  Pneumonia — Application  of  Special 
Methods. 

CHAPTER  XCVIII 

General  Drug  Therapy 723-726 

Routine  Administration  of  Drugs  Productive  of  Very  Injurious 
Effects— Prevailing  Tendency  to  Decry  the  Value  of  all  Medication — 
Protest  Against  this  Popular  Fad — The  Intelligent  Exhibition  of  a 
Few  Remedies  Constitutes  a  Valuable  Adjuvant  to  More  Important 
Measures  of  Treatment. 


SECTION    III 


Specific  Treatment. 


CHAPTER  XCIX 

Theories  of  Immunity 726-738 

Historic  Review — The  Employment  of  Tuberculin — Inoculations 
With  Living  Attenuated  Tubercle  Bacilli — Maragliano's  Method— 
Metchnikoff's  Doctrine  of  Phagocytosis — Opsonins — Bacterial 
Vaccines — Wright's  Method. 

CHAPTER  C 

Personal  Observations  upon  the  Use  of  Bacterial  Vaccines 739-762 

General  Observations — Reports  of  Cases — Conclusions. 


PULMONARY  TUBERCULOSIS 


PART  I 
ETIOLOGY  AND  PATHOLOGIC  ANATOMY 


SECTION   I 

General  Etiologic  Considerations 


CHAPTER  I 

INTRODUCTION 

In  a  work  devoted  essentially  to  the  clinical  aspects  of  pulmonary 
tuberculosis  it  is  manifestly  impossible  to  dwell  at  length  upon  features 
of  a  purely  bacteriologic  nature,  although  they  constitute  data  of  enor- 
mous interest  in  connection  with  the  general  subject  of  tuberculosis.  A 
vast  amount  of  scientific  work  has  been  performed  by  enthusiastic 
students  during  the  cjuarter  century  since  the  discovery  of  the  tubercle 
bacillus  by  Robert  Koch.  The  results  of  their  labors  have  been  of  tre- 
mendous value  from  the  standpoint  of  scientific  investigation,  and  of 
vital  importance  in  the  elucidation  of  practical  problems  pertaining  to 
the  etiology  of  this  disease.  Their  patient  toil  in  the  realm  of  animal 
experimentation  and  of  laboratory  research  has  been  productive  of  such 
a  mass  of  absorbing  medical  literature  as  to  preclude  more  than  its  cur- 
sory mention  even  were  this  book  limited  solely  to  a  historic  review  of 
the  progress  achieved  along  these  lines.  Much  less,  then,  is  detailed 
reference  permitted  to  the  innumervable  contributions  of  the  many 
workers  in  the  field  of  scientific  study,  the  sum-total  of  whose  observa- 
tions is  of  such  infinite  magnitude.  A  volume  of  enormous  proportions 
is  needed  to  accord  justice  and  honor  to  the  noble  work  of  the  earlier 
students. 

It  would,  indeed,  be  a  Herculean  task  for  one  not  especially  trained 
in  the  technic  of  laboratory  methods  nor  fully  conversant  with  the  intri- 
cate details  and  scope  of  previous  investigation  to  attempt  in  review  an 
elaborate  exposition  of  the  achievements  of  individual  students  during 
the  slow  evolution  of  our  present  knowledge  concerning  the  etiology  of 
tuberculosis.  There  is  disclaimed  any  original  scientific  study  or  pro- 
found knowledge  of  the  special  departments  relating  to  bacteriologic  or 
histologic  research.  There  will  be  no  attempt  to  introduce  contributions 
of  this  nature  nor  to  advance  unsustained  personal  opinions  concerning 
the  proper  interpretation  to  be  placed  upon  the  reported  results  of  exper- 


18  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

imental  work  by  others.  In  such  purely  technical  matters  it  is  hoped  to 
voice,  as  far  as  possible,  the  consensus  judgment  of  those  who  are  quali- 
fied by  experience  and  equipment  to  form  lational  conclusions.  Elabo- 
rate scientific  treatises  abound  which  present  in  detail  the  results  of 
individual  observations  concerning  the  tubercle  bacillus  and  the  many 
aspects  of  infection.  The  large  and  comprehen.sive  volume  by  Straus 
upon  the  bacillus  alone  is  an  example  of  the  stupendous  amount  of  litera- 
ture extant  in  relation  to  features  of  etiologic  interest.  An  effort  will  be 
made  in  this  connection  merely  to  review  the  more  practical  and  essen- 
tial etiologic  facts  without  undue  consideration  of  the  various  theories 
as  yet  incapable  of  complete  verification. 

HISTORIC  REVIEW 

Tuberculosis  is,  beyond  question,  the  most  important  disease  with 
which  the  human  race  has  ever  been  obliged  to  contend.  Its  antiquity 
dates  from  the  earliest  records  accessible  to  man.  The  writings  of 
Hippocrates,  460  to  377  B.  C,  contain  a  description  of  the  disease  so 
correct  in  its  essential  details  as  to  equal  a  work  of  modern  excellence. 
From  the  period  of  Galen,  200  B.  C,  until  the  present  time  widely  diver- 
gent conceptions  have  been  entertained  as  to  the  pathology  of  consump- 
tion, but  a  uniform  opinion  has  prevailed  relative  to  its  clinical  character- 
istics. Only  in  comparatively  recent  years,  however,  has  belief  in  its 
curability  become  general.  Recognition  of  nodules  or  tubercles  in  the 
lung  was  obtained  about  the  midclle  of  the  seventeenth  century.  Upon 
beginning  anatomic  investigation  and  with  the  chscovery  of  cavity  for- 
mation and  pus  collections  numerous  conjectures  were  offered  as  to  the 
pathogenesis  of  the  disease.  The  first  efforts  toward  inoculation  experi- 
ments were  made  in  the  early  part  of  the  nineteenth  century,  and  were 
not  attended  with  clearly  definable  results.  Consequenth'  there  was 
much  speculation  concerning  the  possible  infectiousness  or  transmissi- 
bility  of  tuberculosis.  Laennec  contributed  much  to  the  knowledge 
of  the  disease  by  establishing  a  more  definite  relation  between  tubercles 
and  consumption,  and  by  advocating  the  identity  of  pulmonary  and 
glandular  tuberculosis  from  a  pathologic  standpoint.  :iltli(umh  the  spe- 
cific microorganism,  of  course,  was  unknown.  Rokitaiisky  was  an  expo- 
nent of  the  same  doctrine,  but  insisted  upon  the  significance  of  a  certain 
adaptabUity  or  susceptibility  to  consumption,  as  evinced  by  a  peculiar 
type,  or  "phthisical  habitus."  Virchow  cleared  the  atrnosphere  to 
some  extent  by  expounding  the  pathologic  and  histologic  structure  of 
tubercle.  Microscopic  research  had  been  undertaken  previously  by 
Lebert,  who  described  the  so-called  "tubercle  corpuscle"  as  a  non- 
nucleated  cell  in  the  midst  of  tubercle  formation.  The  first  experimental 
evidence  of  the  inoculation  transmission  of  the  di.sease  was  furnished  by 
Klencke  in  184.3.  He  inoculated  rabbits  with  tuberculous  material, 
and  at  autopsy,  twenty-six  weeks  later,  found  cUsseminated  tubercle 
deposit  in  the  liver  and  lungs.  In  1857  Buhl  promulgated  the  doctrine 
of  the  origin  of  miliary  tuberculosis  as  a  result  of  the  distribution,  through 
the  medium  of  the  circulation,  of  an  agent  derived  from  an  area  of  infec- 
tion within  the  body.  Villemin  in  186.5  conducted  a  .series  of  inoculation 
experiments  of  the  greatest  value.  In  addition  to  introducing  into 
animals  an  infective  material  obtained  from  tuberculous  tissues  and  the 
sputum  of  consumptives,  he  injected  into  a  second  class  non-tuberculous 


THE    TUBERCLE    BACILLUS  19 

pus,  and  in  a  third,  the  caseous  matter  from  tuberculous  cows.  A  tuber- 
culous deposit  was  found  after  the  introduction  of  purely  infective 
matter  from  any  source,  confirming  the  theory  of  the  specific  infectious 
nature  of  the  cUsease.  An  apparent  identity  of  human  and  bovine 
tuberculosis  also  was  suggested  by  the  demonstration  of  tuberculous 
changes  in  all  instances  irrespective  of  the  derivation  of  the  infective 
agent.  Despite  vigorous  opposition  and  conflicting  results  of  animal 
experimentation  by  others,  belief  in  the  correctness  of  Villemin's  con- 
clusions became  established  upon  a  firm  basis  through  the  supplemental 
experiments  of  several  observers.  Among  these,  Cohnheim  contrilsuted 
prominently  to  the  acceptance  of  Villemin's  teaching  by  his  method  of 
inoculation  into  the  anterior  chamber  of  the  eye  of  a  rabbit.  By  this 
means  opportunity  was  afforded  for  visual  inspection  of  the  m^nhial 
development  of  pathologic  change.  The  <lisco\ciy  of  t!ie  specific  micro- 
organism in  tuberculous  tissues  and  its  etiojo.uic  relation  to  the  (l<'\-e|op- 
ment  of  the  disease  in  man  and  lower  animals  was  made  bj^  Rol:)ert  Koch 
in  1882.  By  an  original  method  of  differential  staining  he  succeeded 
in  isolating  the  tubercle  bacillus  and  showed  its  presence  in  infected 
areas  in  all  parts  of  the  body.  Previous  to  this,  characteristic  tubercle 
formation  had  been  recognized  in  the  scrofulous  affections  of  glands, 
bones,  and  joints,  although  the  precise  infective  agent  had  not  been 
discovered.  Koch  demonstrated  the  absence  of  tubercle  bacilli  in  other 
than  tuberculous  conditions,  and  even  accomplished  the  successful 
inoculation  of  animals  from  pure  artificial  cultures  of  tubercle  bacilli 
after  the  elimination  of  all  extraneous  elements  and  the  removal  of 
accessory  sources  of  error.  Koch  thus  established  the  cause  of  tubercu- 
losis among  man  and  animals  by  the  discovery  of  the  bacillus  and  the 
results  of  inoculation  experiments.  The  apparent  etiologic  identity  of 
all  forms  of  tuberculosis  in  different  species  was  determined  also  upon 
the  basis  of  the  characteristic  histologic  structure  of  the  primary  tid>er- 
cle.  Since  this  time  a  mass  of  evidence  has  been  presented  by  numerous 
observers  both  for  and  against  the  acceptance  of  essential  differences 
in  the  cultural  characteristics,  virulence,  and  powers  of  transmission 
of  the  bacillus  in  the  several  animals  in  which  a  natural  habitat  is  found. 
Despite  a  degree  of  similarity  of  the  clinical  manifestations  in  different 
species,  important  difference.?,  referable  to  the  bacillus  of  various  types 
have  been  noted  and  will  be  the  subject  of  future  discussion.  The  tuber- 
cle bacillus  of  human  origin  is  of  more  essential  present  interest. 


CHAPTER    II 

THE  TUBERCLE  BACILLUS 

In  view  of  all  that  has  been  written  of  this  microorganism,  attention 
will  be  called  merely  to  a  few  of  its  more  important  features.  The 
tubercle  bacillus  is  a  small,  immobile  rod  of  somewhat  varying  size  and 
shape.  Tlie  average  length  has  been  described  as  from  one-fourth  to 
one-half  the  diameter  of  a  red  blood-corpuscle.  Differences  in  length, 
however,  are  found  to  e.xist  in  accordance  with  the  virulence  of  the 


20  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

bacilli  and  the  age  of  the  culture.  An  evidence  of  attenuation  is  found 
in  a  greater  lengthening  and  thinning  of  the  microorganism,  and  of 
virulence  by  the  presence  of  short,  thick  bacilli.  A  considerable  vari- 
ation in  size  is  recognized  in  bacilli  taken  from  the  sputum,  which,  as 
a  rule,  are  of  greater  length  than  those  observed  from  culture  growth. 
Differences  also  exist  in  the  contour  or  shape  of  the  microorganisms, 
in  their  disposition  with  reference  to  one  another,  and  in  their  specific 
staining  reaction.  A  notched,  beaded,  or  clubbed  appearance,  with  a 
tendency  toward  flexion,  is  suggestive  of  an  old  attenuated  bacillus. 
A  fragmentary  or  broken-down  rod  also  is  strongly  indicative  of  degener- 
ative change.  On  the  other  hand,  the  aggregation  of  bacilli  in  clumps, 
as  opposed  to  an  isolated  or  scattered  disposition,  is  somewhat  character- 
istic of  active  virulence.  The  same  is  true  of  their  ability  to  take  rapidly 
a  deep  primary  stain.  An  essential  property  of  the  tubercle  bacillus  is 
its  resistance  to  decolorization  by  acids.  On  account  of  this  attribute 
it  is  easy  to  recognize  the  bacillus  in  the  sputum  after  the  removal  of  the 
primary  stain  from  the  cellular  elements  and  associated  bacteria.  The 
subsequent  blue  contrast  stain  of  these  portions  of  the  specimen  renders 
the  continuous  red  color  of  the  bacilli  especially  pronounced.  An  impor- 
tant preliminary  to  the  staining  process  is  the  selection  from  the  midst 
of  the  tuberculous  sputa  of  small  cheesy  particles  often  found  in  the 
more  dependent  portions.  Tubercle  bacilli  are  much  more  frequent  in 
these  caseous  deposits  than  elsewhere  in  the  expectoration.  When  the 
bacilli  are  particularly  scanty,  it  is  sometimes  advisalale  to  dilute  100  c.c. 
of  sputum  with  200  c.c.  of  water  to  which  have  been  added  about  8  drops 
of  a  10  per  cent,  solution  of  sodium  hydroxid.  A  homogeneous  solution 
is  obtained  by  boiling,  and  the  centrifuged  sediment  is  examined  for 
tubercle  bacilli.  A  thin  smear  of  this  portion  of  the  .sputum  should  be 
made  either  upon  the  cover-glass  or  the  slide.  Several  methods  of  stain- 
ing are  employed,  notably  the  procedures  of  Gabbet,  Ehrlich,  the 
Weigert-Ehrlich,  the  Ziehl-Neelsen,  and  the  Pappenheim.  The  principle 
employed  in  each  instance  is  the  production  of  a  deep,  primary  red  .stain 
with  carbol-fuchsin  and  the  subsequent  decolorization  of  ail  portions 
of  the  specimen  except  the  tubercle  bacilli,  which  later  are  made  more 
conspicuous  by  the  contrast  stain  of  the  cellular  elements.  The  carbol- 
fuchsin  solution  is  composed  of  one  part  of  fuchsin,  100  parts  of  a  5  per 
cent,  solution  of  phenol,  and  10  parts  of  alisolute  alcohol.  The  decolori- 
zation is  scruicd  ]<Y  a  dilute  -oluticiii  of  sulpluiric,  nitric,  or  hydrochloric 
acid.  The  -incai--  arc  alluwcil  \n  ilry  in  tlie  air  upon  the  cover-glass  and 
later  are  fixed  In'  bcin-  pa-scd  i|iiickly  three  times  through  the  flame  of 
an  alcohol  lamp  or  Hun-iii  I  hiuht.  The  specimen  is  then  ready  for  .stain- 
ing with  the  carbol-iiirli-ui  -"lution.  It  was  formerly  the  practice  to 
immerse  the  cover-glass  in  tliis  solution  for  twenty-four  hours,  but  by 
the  use  of  heat  this  process  may  be  shortened  to  a  few  minutes.  A 
convenient  and  rapid  wa.v  of  staining  consists  of  placing  a  few  drops 
of  the  carbol-fuchsin  solution  upon  the  cover-glass  and  holding  this 
for  a  few  minutes  over  the  flame.  The  fluid  should  be  allowed  to  simmer 
or  steam,  but  must  not  be  brought  to  the  boiling-point.  At  the  end 
of  one  minute  the  specimen  is  washed  with  water  and  decolorized  by 
adding  a  few  drops  of  25  per  cent,  solution  of  sulphuric  acid.  The 
decolorization  should  be  repeated  once  or  twice  until  the  film  upon  the 
cover-glass  when  held  to  the  light  appears  colorle.ss  and  opaque.  The 
process  is  made  more  complete  by  the  addition  of  a  few  drops  of  98  per 


THE    TUBERCLE    BACILLUS  21 

cent,  alcohol.  After  washing,  the  specimen  is  stained  with  methylene- 
blue  for  about  thirty  seconds,  although  no  harm  results,  as  a  rule,  if 
this  is  permitted  to  remain  for  a  considerably  longer  period.  After 
washing  again  with  water  and  drying  the  specimen  usually  is  mounted 
in  Canada  balsam. 

The  retention  of  the  primary  stain  by  the  microorganism  is  of  exceed- 
ing value  in  the  differentiation  of  the  true  from  the  pseudotubercle 
bacillus.  There  remain,  however,  a  considerable  number  of  acid-fast 
bacilli  which  closely  resemble  the  tubercle  bacillus  in  other  respects. 
For  this  reason  the  appellation  "pseudotubercle  bacillus'"  is  usually 
restricted  to  bacteria  which  simulate  the  appearance  of  tubercle  bacilli 
and  do  not  yield  to  acid  decolorization.  Among  the  varieties  which  do 
not  surrender  their  primary  stain  upon  the  employment  of  acids  the 
smegma  bacillus  is  the  most  important,  as  the  presence  of  this  micro- 
organism may  lead  to  unfortunate  errors  of  diagnosis  involving  to  a  vast 
degree  the  well-being  of  the  patient.  In  cases  susceptible  of  reasonable 
doubt  a  staining  in  accordance  with  the  ordinary  methods,  must  lead  to 
inevitable  confusion  in  the  interpretation  of  results.  It  is  found  that 
the  smegma  bacillus  holds  its  color  after  a  prolonged  exposure  to  absolute 
alcohol,  but  yields  its  stain  upon  boiling  in  alcohol.  Aronson  has  shown 
that  the  tubei'cle  bacillus  contains  wax  and  fatty  acids,  on  account  of 
which  combination  the  microorganism  is  acid  fast.  The  smegma  bacil- 
lus, on  the  other  hand,  has  fat  and  sebaceous  matter  in  place  of  wax. 
This  bacillus  may  be  robbed  of  its  fat  by  boiling  in  alcohol,  which  has 
slight  effect  upon  the  wax  contained  in  the  tubercle  bacillus.  Bienstock 
and  Gottstein  were  able  to  treat  other  bacilli  with  fats,  as  butter,  lanolin, 
paraffin,  and  wax,  and  make  them  acid  fast.  By  the  addition  of  these 
substances  to  several  culture-media  they  were  able  also  to  give  a  degree 
of  acid-fastne.ss  to  bacilli  which  otherwise  yielded  to  acid  decolorization. 
Various  procedures  are  employed  for  the  differential  staining  of  the  true 
and  the  smegma  bacillus,  all  based  upon  the  application  of  the  influence 
of  alcohol.  The  use  of  inorganic  acids  is  found  of  no  value.  P;i]i])en- 
heim  has  devised  a  method  which  produces  a  ready  decolorization  of  the 
smegma  bacillus  by  fluorescein-alcohol.  After  the  production  of  the 
primary  stain  the  preparations  are  immersed  several  times  in  Pappen- 
heim's  .solution,  which  consists  of  one  part  of  corallin  in  100  parts  of 
absolute  alcohol,  to  which  methylene-blue  is  added  to  saturation  and 
diluted  with  20  parts  of  glycerin  (Simon).  As  a  practical  matter,  error 
in  the  differentiation  of  the  bacilli  may  take  place  principally  in  connec- 
tion with  genito-urinary  tuberculosis.  It  is  now  the  custom  of  clinicians 
and  surgeons  to  insist  upon  catheterized  specimens  of  urine  before  sub- 
mission to  bacteriologists  for  examination.  This  plan  obviates  to  a 
degree  the  danger  of  confusing  the  tubercle  bacillus  with  the  smegma 
microorganism. 

The  lepra  bacillus  is  of  but  slight  interest  to  practitioners  in  this 
country.  It  presents,  however,  several  points  of  resemblance  to  the 
tubercle  bacillus,  particularly  in  form  and  staining  reaction.  Cornet 
has  referred  to  the  disposition  of  the  lepra  bacilli,  as  pointed  out  by 
Babes,  this  feature  distinguishing  them  from  the  tubercle  bacillus.  The 
former  are  found  by  preference  within  the  cell  and  grouped  very  closely 
together.  The  latter  are  usually  without  the  cells,  but  if  intracellular, 
do  not  arrange  themselves  in  such  dense  masses  as  to  obscure  the  nucleus. 
He  also  calls  attention  to  the  comparative  rapidity  with  which  the  lepra 


22  ETIOLOGY    AND    PATHOLOGIC    AXATOMY 

bacillus  takes  the  primary  stain  and  its  ability  to  do  this  even  ^nthout 
the  exhibition  of  heat,  a  quality  not  possessed  by  the  tubercle  bacillus. 
According  to  James,  there  are  now  thirty  microorganisms  more  or  less 
resembling  the  tubercle  bacillus  in  form,  and  almost  equally  resistant 
to  acids.  A  close  analogy  has  been  suggested  between  these  varieties 
and  the  tubercle  bacillus,  the  essential  difference  pertaining  to  evolution- 
ary changes  of  adaptabilitj'  in  accordance  with  a  varying  environment. 
These  microorganisms  are  not  found,  as  a  rule,  within  the  body,  though 
occasionally  they  do  occur  in  the  sputum,  feces,  or  secretions  from  nose 
and  pharynx  and  within  the  tonsillar  crypts.  They  are  distributed,  to 
some  extent,  in  the  vegetable  kingdom  and  in  the  excrement  and  secre- 
tions of  animals  accustomed  to  herbivorous  diet.  The  most  important 
of  these  microorganisms  is  the  timothy-grass  bacillus.  Others  have 
been  found  in  milk,  butter,  manure,  and  earth  subjected  to  fertilization. 
The  grass  bacillus,  unlike  the  other  varieties  mentioned,  will  grow  at 
the  same  temperature  as  the  tubercle  bacillus,  and  is  thought  to  be 
equally  resistant  to  external  influences.  Its  discoverer,  Moeller,  claims 
to  have  been  able  to  produce  the  same  lesions  with  this  agent  as  with  the 
tubercle  bacillus,  but  finds  cultural  cUfferences  and  a  much  diminished 
virulence. 

The  cultural  characteristics  of  true  tubercle  bacilli  consist  of 
their  very  slow  growth  and  the  necessary  maintenance  of  a  high 
temperature,  approximating  that  of  the  blood.  Cultures  may  be  ob- 
tained from  tuberculous  tissue  and  infected  sputum.  The  usual  method 
is  to  inoculate  a  small  portion  of  the  sputum  or  infective  material  into 
a  healthy  gumea-pig.  After  about  three  weeks  the  animal  is  killed, 
and,  under  strict  aseptic  precautions,  the  tubercles  are  dissected  from 
the  tissues  and  transplanted  into  culture-media.  Colonies  may  also  be 
produced  by  the  direct  implantation  of  tuberculous  material  into  the 
various  culture-media;  this  method,  however,  being  quite  difficult. 
This  is  done  by  thorough  rubbing  of  the  surface  of  the  media  with  an 
infected  platinum  loop.  The  medium  may  be  solid  or  liquid,  and  con- 
sist of  blood-serum,  bouillon,  glycerin-agar,  or  glycerin  bouillon.  After 
a  period  of  two  or  three  weeks  in  the  incubator  at  a  temperature  of  37°  C, 
there  is  found  upon  the  surface  of  the  culture-medium  a  growth  re- 
sembling an  irregular  cauliflower  excrescence,  yellowish  white  in  color, 
and  of  a  peculiarly  dry  or  crumbly  appearance.  When  cultivated  in 
bouillon,  a  small  scale  from  a  solid  culture-medium  is  transplanted 
to  the  liquid  in  such  a  manner  that  it  floats  upon  the  surface.  By  means 
of  Hesse's  Niihrboden  spread  in  Petri  dishes  the  time  may  be  shortened 
from  ten  days,  which  was  required  by  the  older  methods,  to  four  or  five 
days,  the  fresh  sputum  being  deposited  upon  the  medium  liy  drawing 
a  portion  of  the  .slimy  pus  over  its  surface.  Successive  transplantation 
to  new  media  results  in  more  profuse  vegetation  and  a  more  luxuriant 
flora.  Some  observers  attribute  a  diminished  virulence  to  cultures  of 
rapid  and  luxuriant  growth,  and  an  increased  pathogenic  power  to  thoise 
difficult  of  cultivation  and  of  scant  growth.  This  is  the  opinion  of 
Lartigau,  as  the  result  of  experimental  inoculation.  The  cultural  vital- 
ity also  of  the  tubercle  bacillus  is  supposed  to  diminish  with  the  rapidity 
of  growth.  Temperature  greatly  in  exce-ss  of  that  of  the  blood  is  ex- 
tremely detrimental  to  its  vital  resistance.  Its  growth  is  destroyed  at  42° 
C,  and  the  bacillus  quickly  becomes  extinct  at  70°  C.  A  distinctly  inhib- 
itory influence  upon  its  development  is  ascribed  to  sunlight,  especiallj'  if 


Tubercle  bacilli  from  specimen  of  sputum.  Bacilli  led,  other  organisms  and 
tissues  blue.  The  so-called  attenuated  variety  of  tubercle  bacilli.  Note  the  elongated 
rods,  some  of  which  are  notched  and  beaded.  Note  also  faintntss  and  irregularity 
of  stain. 


THE    TUBERCLE    BACILLUS  23 

the  microorganism  is  exposed  to  the  direct  rays.  It  is  much  more  resistant 
to  cold,  however,  and  is  claimed  by  some  to  retain  its  vitality  after  freez- 
ing. The  period  of  retention  by  bacilli  of  their  pathogenic  vh'ulence  under 
various  external  conditions  has  been  the  subject  of  much  experimental 
observation.  While  the  testimony  of  several  workers  in  this  field  of 
research,  which  is  possessed  of  so  much  practical  interest,  is  somewhat 
conflicting,  there  seems  to  be.  on  the  whole,  a  fairly  uniform  belief  in 
the  approximate  duration  of  its  ^■itality  under  similar  conditions.  In 
1869  Villemin  determined  the  retcutinu  of  \irulence  in  sputum  after 
several  weeks.  Schill  and  Fisclici'  f(iuiid  that  bacilli  contained  in  dry 
sputum  preserved  their  vitalit>-  for  six  numtlis,  l.ui  iatcl\-  Imiuer.  Other 
observers  have  found  the  \itality  tn  \ar\  within  wide  limits  under  differ- 
ing conditions.  Some  report  a  loss  of  virulence  after  two  or  three  months 
at  most,  and  others  not  until  after  nine  months.  Cornet  assumes  that, 
under  ordinary  circumstances,  the  vitality  is  destroyed  in  about  three 
months,  and  that  a  retention  of  pathogenic  power  for  a  period  of  six 
months  is  exceedingly  rare  and  occasioned  only  by  the  existence  of 
extraordinary  conditions.  It  is  evident  that  the  lack  of  uniformity  of 
results  is  attributable  to  essential  differences  in  the  conchtions  to  which 
the  sputum  is  subjected,  viz.,  the  thickness  of  the  layer,  the  exposure 
to  the  sun  or  to  diffused  sunlight,  and  the  degree  of  moisture  and  wind 
as  determined  by  seasonable  changes.  In  this  coiuiection  it  is  reasonable 
to  assume  that  il'  di'st  luction  of  growth  and  \italit\-  ensues  as  a  direct 
result  of  fundainciital  atliibutes  of  weatlicf.  iiicliiding  sunshine,  degree 
of  moisture,  air  movement,  etc.,  important  lUffcrences  inevitably  must 
accompany  the  climatic  conditions  under  which  the  experiments  are 
conducted.  In  other  words,  if  sunshine  and  dryness  are  essential  factors 
to  overcome  the  vitality  of  the  bacilli,  widely  varying  results  should 
be  reported  during  seasons  when  rains  do  not  prevail  and  in  localities 
where  sunshine  is  almost  continuous.  To  this  end  the  experiments  of 
Gardiner,  of  Colorado  Springs,  at  an  altitude  of  6000  feet,  are  of  con- 
siderable interest.  C5ardiner  exposed  to  the  direct  rays  of  the  sun, 
sputum  from  a  tuberculous  patient  containing  bacilli  of  e.stablished 
virulence.  The  sputum  remamed  for  varying  periods  upon  sandstone 
and  wood.  It  was  found  that  a  hard,  superficial  crust  formed  in  the 
process  of  drying,  and  that  it  was  impossible  to  detach  even  minute 
quantities  from  this  surface  with  the  blow-pipe.  Actual  grinding  of 
the  cru-st  was  required  in  order  to  produce  distribution  of  the  bacilli. 
After  one  and  three-quarter  hours  of  exposure  the  sputum  was  rubbed 
up  with  sterilized  water  and  inoculated  into  guinea-pigs,  with  positive 
results  in  one  case.  It  is  noteworthy,  ho\\c\cr,  that  the  portion  selected 
for  inoculation  was  taken  from  a  mass  of  omt  two  drams  of  unsmeared 
sputum,  the  upper  surface  of  which  had  hardened  into  an  impermeable 
crust. 

Ransome  and  Delephine  had  previously  conducted  an  elaborate 
series  of  experiments  which  showed  the  preponderating  influence  of 
direct  sun.shine  as  a  destroyer  of  bacillary  activity.  Sputum  exposed 
to  light  (not  direct  sun's  rays)  and  air  for  forty-five  days  did  not  pro- 
duce tuberculosis  after  inoculation  of  rabbits.  An  exposure  to  air 
without  sunlight  during  the  same  period  was  insufficient  to  destroy 
the  power  of  transmitting  the  disease.  Guinea-pigs  were  found  to 
respond  positively  to  sputum  exposed  to  air  in  dark  places,  but  neg- 
atively if  the  sputum  had  been  subjected  to  diffused  light  as  well  as  air 


24  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

for  an  equal  length  of  time.  It  was  found  that  an  exposure  to  light 
for  three  days  and  one  hour  was  sufficient  to  render  the  bacilli  inert. 
The  inference  was  gained  from  these  observations  that  sunshine  was 
the  all-important  factor  for  the  destruction  of  the  pathogenic  virulence 
of  the  bacilli.  To  what  extent  moisture  or  dryness  entered  into  the 
elucidation  of  the  problem  was  not  determined  at  that  time.  Migneco 
found  that  the  bacilli  in  dried  sputum  were  not  killed  until  from  twenty 
to  thirty  hours'  exposure  to  sunlight  in  Italy.  In  1899  MitcheU  and 
Crouch,  of  Denver,  after  an  elaborate  investigation,  found  dried  sputum 
to  be  quite  virulent  up  to  twenty  hours'  exposure  in  direct  sunlight, 
after  which  the  virulence  became  attenuated  and  was  lost  in  about 
thirty-five  hours'  exposure.  Recent  observations  by  Twitchell  have 
been  conducted  most  carefully  and  furnish  desirable  information  con- 
cerning the  influence  of  dryness  and  temperature  as  well  as  sunlight. 
Direct  sunshine  was  found  capable  of  rendering  bacilli  inert  after  a  few 
hours,  which  result  is  much  in  accord  with  that  of  Koch,  who,  in  1890, 
asserted  that  destruction  ensued  in  from  a  few  minutes  to  several 
hours.  Straus  found  bouillon  cultures  were  killed  in  two  hours. 
Twitchell's  technic  was  evolved  so  perfectly  and  the  conclusions  are 
so  incontrovertible  that  a  brief  abstract  of  his  methods  and  results  is 
appended: 

One  c.c.  of  virulent  sputum  from  two  patients  with  active  tuber- 
culosis was  deposited  in  sterilized,  corked,  and  paraffined  white  glass 
bottles,  3  c.c.  in  diameter,  with  a  depth  of  1  c.c.  One  bottle  was  placed  in 
a  dark,  moist  box,  and  similar  bottles  in  a  dark  closet,  and  in  the  diffused 
light  of  an  ordinary  room.  In  another  series  of  experiments  the  bottles 
were  exposed  to  like  conditions,  but  were  stoppered  with  cotton.  Still 
again  the  .sputum  was  deposited  in  sand  within  the  bottles,  with  the 
bottles  corked  and  paraffined  in  some  instances  and  unsealed  in  others. 
Sputum  deposited  in  sterilized  white  glass  bottles  with  and  without 
sand,  sealed  and  unsealed,  were  placed  in  the  thermostat.  Open  white 
glass  bottles  of  sputum  were  deposited  in  the  open  air  during  the  winter 
months.  Corked  and  paraffined  bottles  were  buried  in  the  ground.  Other 
bottles  corked  and  paraffined  were  packed  in  ice  or  frozen  in  blocks  of 
ice.  Sputum  was  deposited  upon  handkerchiefs,  carpets,  wood,  and 
woolen  blankets  under  ordinary  room  conditions.  Subsequent  in- 
oculation experiments  with  the  sputum  placed  in  sand  and  in  blocks  of 
ice  were  not  satisfactory.  The  sputa  placed  in  a  dark  moist  box  or  a  dark 
closet,  under  the  varying  conditions  described,  produced  tuberculous  le- 
sions in  guinea-pigs  after  one  hundred  and  fifty-seven  days,  but  in  no  in- 
stance after  one  hundred  and  eighty-eight  daj's.  Positive  results  attended 
the  inoculation  of  guinea-pigs  with  sputum  contained  in  paraffined  bottles 
after  exposure  to  the  diffused  light  of  an  ordinary  room  for  one  hundred 
and  twenty-four  days,  but  not  after  one  hundred  and  seventy-five  days. 
The  sputum  in  open  bottles  placed  out-of-doors  in  the  winter  months 
produced  tuberculous  lesions  after  one  hundred  and  ten  days,  but  not 
after  one  hundred  and  thirty-two  days;  the  sputum  from  ice  after  one 
hundred  and  two  days,  but  not  after  one  hundred  and  fifty-three;  from 
a  handkerchief  or  woolen  blanket  after  .seventy  days,  but  not  after  one 
hundred  and  ten.  The  same  was  true  of  the  sputum  deposited  upon 
wood.  Tuberculous  lesions  were  produced  by  the  inoculation  of  sputum 
deposited  upon  the  carpet  after  thirty-nine  days,  but  not  after  seventy; 
upon  the  sand  in  a  light,  dry  place  after  thirty  days,  but  not  after 


Fig.  1. — Tubercle  bacilli  from  specimen  of  sputum— the  so-called  virulent  type. 
Note  the  short,  bright-staining  rods,  also  presence  of  clumps.  Note,  further, 
broken-down  appearance  of  cells  and  tissue.  This  is  from  patient  having  very  large 
cavity.     See  radiograph,  Fig.  72,  p.  276. 


Fig.    2.— Bacilli 
decolorized  by  alcolio 


undoubtedly    smegma — fro 
;   same  case  as  preceding. 


ifugcd    specimen    of    urine ; 


THE    TUBERCLE    BACILLUS  25 

seventy.  The  sputum  exposed  to  the  direct  rays  of  the  sun  was  found 
productive  of  a  tuberculous  lesion  after  one  hour,  but  not  after  seven 
hours. 

Culture  growth  of  the  tubercle  bacillus  has  been  known  for  years  to 
be  inhibited  by  the  introduction  into  the  media  of  a  variety  of  substances 
in  certain  proportions.  Chief  among  these  are  creasote  and  iodoform. 
The  practical  application  of  their  action  upon  tubercle  bacilli  has  been 
attempted  by  means  of  inhalations  of  the  former,  local  injections  of  the 
latter,  and  internal  administration  of  each.  Although  favorable  results 
have  been  reported  from  time  to  time,  their  use  in  general  has  been 
disappointing  and  sometimes  injurious.  The  human  body,  on  account 
of  innumerable  complicating  conditions  and  processes,  is  not  to  be 
adjudged  a  culture-medium  upon  the  basis  of  which  internal  therapeusis 
is  to  be  determined.  The  life  of  the  bacillus  external  to  the  body  is 
found  to  be  destroyed  by  the  action  of  numerous  chemicals  and  by  pro- 
longed boiling.  Corrosive  sublimate,  so  freely  employed  for  the  dis- 
infection of  sputum,  is,  as  a  matter  of  fact,  of  little  value  on  account  of 
the  protective  coating  of  the  bacillus  by  the  coagulation  of  the  albumi- 
nous matter.  Twenty-four  hours  is  required  for  the  destruction  of  the 
vitality  of  the  bacilli  by  a  5  per  cent,  solution  of  phenol.  The  presence 
of  various  bacteria  in  culture  experiments  or  in  decomposing  sputum  is 
inimical  to  the  growth  of  tubercle  bacilli.  This  is  due  to  the  compara- 
tively rapid  growth  and  development  of  other  microorganisms. 

The  chemic  composition  of  the  tubercle  bacillus  has  been  the  sub- 
ject of  careful  investigation,  which  has  been  reported  by  Hammerschlag, 
Behring,  Hoffmann,  de  Schweinitz,  Aronson,  Ruppel,  Levene,  Baldwin, 
and  Trudeau.  It  is  evident,  as  a  result  of  their  research,  that  the  fatty 
or  waxy  constituent  is  of  considerable  importance  and  obtains  in  much 
larger  proportion  than  is  the  case  with  other  bacteria.  This  has  been 
found  to  be  the  only  portion  of  the  bacillus  to  retain  the  stain  after  the 
exhibition  of  the  acicl,  all  the  other  component  parts  surrendering  the 
color  immediately.  Baldwin  has  shown  that  the  fat,  however,  is  not  an 
element  of  material  significance  in  the  production  of  toxemia,  as  the 
tuberculin  reaction  was  present  in  animals  previously  inoculated  with 
fat-free  bacilli.  While  the  fat  may  be  assumed  to  form  an  average  of 
30  per  cent,  of  the  substance  of  the  bacillus,  a  considerable  variation  has 
been  found  in  the  relative  proportions  by  different  observers.  These 
fluctuations  have  been  ascribed  to  the  employment  of  various  media 
and  to  the  differences  of  method  in  estimating  the  amount  of  fat.  Both 
Trudeau  and  Baldwin  have  reported  separately  the  results  of  Levene's 
work  in  connection  with  the  nucleoproteids.  Three  distinct  forms  of 
these  substances  were  recognized,  all  containing  phosphorus.  Nucleic 
acid  was  found  by  Levene  and  Ruppel  after  treating  the  watery  extract 
of  pulverized  tubercle  bacilli  with  acetic  acid  and  analyzing  the  resulting 
filtrate.  The  toxic  properties  of  the  bacillus  are  referable  to  this  deriv- 
ative. Levene  and  others  have  demonstrated  also  the  presence  of 
carbohydrates. 

VARIOUS  TYPES  OF  TUBERCLE  BACILLI 

It  has  been  shown  that  numerous  microorganisms  closely  resemble 
the  tubercle  bacillus  in  form,  size,  and  staining  reaction,  but  exhibit 
differences  in  cultural  characteristics,  especially  with  reference  to  less- 


26  ETIOLOGY    AND    PATHOLOGIC    AXATOMY 

ened  resistance  and  greater  susceptibility  to  temperature  conditions.  In 
addition  to  the  variations  of  virulence  and  growth  among-  tubercle 
bacilli  it  has  been  found  that  other  differences  exist  according  to  their 
habitat. 

Theobald  Smith  has  called  attention  to  what  he  terms  "  the  complex 
relationship  established  in  time  by  a  selective  adaptation  between  two 
living  organisms,  of  which  one  is  the  parafsite  of  the  other."  He  empha- 
sizes the  interdependence  of  both  organisms,  and  ascribes  a  disturbed 
equilibrium  between  the  two  as  a  sufficient  cause  for  important  clumges 
in  the  bacillus  as  well  as  in  the  host.  These  differences  in  the  cultural 
attributes  of  the  bacilli,  their  virulence,  and  the  character  of  resulting 
pathogenic  processes  are  capable  of  explanation  upon  the  basis  of  funda- 
mental changes  in  the  species,  in  which  the  bacUlus  is  permitted  to  abide 
with  a  forced  adaptation  to  the  environment. 

Irrespective  of  these  broadly  conceived  hypotheses,  which  are  worthy 
of  the  utmost  consideration,  it  is  true  that  essential  differences  are  recog- 
nized between  several  distinct  types  of  tubercle  bacilli,  i.  e.,  those  of 
human  origin,  the  bovine,  the  avian,  and  the  bacilli  of  fish  or  other 
cold-liloodcil  animals.  The  human  and  bovine  forms  are  described  as 
mammalian  liarilli.  which,  with  the  avian,  have  certain  characteristics 
in  cent  ladi-^i  inctiDii  to  the  bacilli  found  among  fish.  The  latter  bacillus  is 
unable  to  survive  at  the  temperature  of  the  human  body,  and,  therefore, 
is  incapable  of  transmitting  tuberculosis  to  man  or  animals.  Among  the 
three  varieties  of  bacilli  sometimes  found  in  warm-blooded  animals,  the 
avian  presents  important  features  of  dissimilarity  in  comparison  with 
the  human  and  bovine  forms.  Rivolta,  Maffucci,  Ribbert,  Straus,  and 
Koch  have  pursued  investigations  concerning  the  relation  of  this  to  the 
other  types  of  tidaerde  bacilli.  The  avian  bacillus  was  found  to  with- 
stand a  greater  degree  of  heat  than  the  human  or  bovine,  its  growth  not 
being  inhibited  until  after  the  temperature  was  elevated  nearly  two 
degrees  higher  than  was  required  for  other  forms  of  tubercle  bacilli. 
Birds  upon  inoculation  with  human  bacilli  were  found  to  exhibit  liut 
slight  local  reaction,  without  evidence  of  constitutional  change.  Nocard 
showed  that  mammalian  bacilli  grown  in  sacs  of  collodion  within  the 
peritoneal  cavity  of  chickens  could  be  modified  to  such  an  extent  as 
to  produce  tuberculosis  in  fowl.  On  the  other  hand,  Courmont  and 
Dor  demonstrated  that  when  the  avian  bacillus  was  grown  at  lower 
temperatures  and  passed  through  rabbits  it  became  endowed  with  jiatho- 
genic  property  for  mammalia.  Roemer  reported  that  an  interesting 
epizootic  amoiiLi,  (  hickciis  resulted  from  eating  the  entrails  of  a  tubercu- 
lous cow.  Shatiixk.  Scji^man,  Dudgeon,  and  Panton.  in  a  recent  study 
of  the  relatiousiii]!  Iictwecn  avian  and  human  tubercle  Iiacilli,  conclude 
that  the  human  \ariety  is  but  slightly  pathogenic  to  the  pigeon,  and 
when  introduced  with  food  into  the  digestive  canal,  induces  no  local 
lesions  of  the  intestine  or  abdominal  viscera.  They  report  that  but 
slight  local  or  glandular  processes  are  produced  by  the  injection  of  human 
bacilli  into  the  muscles  or  subcutaneous  tissues.  Curiously  conflicting 
results  were  obtained  from  inoculation  of  the  rabbit  and  guinea-pig 
with  avian  bacilli,  the  former  quickly  yielding  to  ovncral  infection  and 
the  latter  exhibiting  but  slight  susceptibility.  Thi-c  louli^are  all  the 
more  remarkable  in  view  of  the  relatively  greater  icsisiainf  ni  the  rabbit 
than  the  guinea-pig  to  human  bacilli.  Flexner  has  called  attention  to 
the  fact  that,  in  spite  of  the  susceptibility  of  the  rabbit  to  the  avian 


THE    RELATION    OF    HUMAN    AND   BOVINE    BACILLI  27 

bacillus,  the  pathologic  processes  are  radically  different  from  those 
appearing  as  a  result  of  infection  with  mammalian  bacilli.  He  cites  the 
absence  of  tubercles  and  caseation  in  the  presence  of  an  enlarged  spleen. 
The  avian,  although  occasionally  present  in  lower  animals,  have  never 
been  discovered  in  man. 


CHAPTER   III 
THE  RELATION  OF  HUMAN  AND  BOVINE  BACILLI 

The  relation  of  human  and  bovine  tuberculosis  for  several  years  has 
engaged  the  attention  of  the  best  observers.  Koch,  upon  announcing 
the  discovery  of  the  tubercle  bacillus  in  1SS2,  proiiiiiltiatcd  the  dictum 
that  human  and  bovine  tiibciculdsis  wcic  ulcniical,  nml  tliaf  the  bovine 
type  was  directly  transmissible  Id  man.  \iicli(i\\  had  stated  in  1863 
that  the  two  chseases  were  entirely  distinct.  This  view,  however,  after 
the  assertion  of  Koch,  was  not  accepted  by  the  profession  in  spite  of  the 
fact  that  Chauveau,  Giinther,  Harms,  and  Bollinger,  after  feeding  calves, 
swine,  and  goats  with  human  tuberculous  material,  had  failed  to  produce 
tuberculosis,  although  these  animals  quiclNl\  succumlied  if  the  food 
contained  milk  and  pieces  of  lung  from  luliciculdiis  cattle.  In  1893 
Baumgarten  questioned  the  complete  identit_y  of  tlie  two  diseases  and 
cited  the  previous  failures  to  effect  a  transmission  of  tuberculosis  to  cattle 
through  the  medium  of  human  bacilli.  He  also  reported  work  done  by 
Gaiser  under  his  direction  to  substantiate  the  correctness  of  his  view. 
A  calf  inoculated  with  human  bacilli  exhibited  no  evidence  of  disease, 
and  when  killed  after  several  months  showed  no  trace  of  tuberculous 
change.  Another  subjected  to  iiKiciilatidu  with  b(i\ine  liaeilli  in  the 
anterior  chamber  of  the  eye  and  in  the  Hank,  ihs|ilayed  a  ty])ical  tuber- 
culous process  of  the  eye,  and  aller  much  emaciation  dieil  in  six  weeks, 
showing  at  autopsy  general  iniliai\  tubeicuhisis.  In  IN'.IN  Smith,  in 
this  country,  obtained  negainc  icsults  iVcmi  iln'  incicnlaiKin  i<\'  cattle 
with  human  liacilli.  Similai-e\|)eiinients  were  iccorded  by  I'mlhinnhani 
and  Dinwiddle  in  the  following  year.  Their  conclusions,  however, 
were  not  to  the  effect  that  human  tuberculosis  was  incapable  of  trans- 
mission to  cattle,  but  merely  that  the  bovine  bacillus  possessed  a  higher 
pathogenic  power  for  these  animals  than  the  l)acilli  of  hnman  origin,  to 
which  the  cattle  were  believed  to  be  more  or  less  i(si>ian(.  Theol)old 
Smith  had  expressed  doubt  as  to  the  absolute  idenlii\  n\  the  two  dis- 
eases, but  did  not  advance  the  theoiy  of  ini|j(issil  lilii  y  of  i  lansmission. 
Koch,  however,  in  1901  openly  disaAdwed  his  pivxidu-  conclusions  and 
maintained  that  human  tuberculosis  dillered  trom  hox me  and  coul.l  not 
be  transmitted  to  cattle.  He  also  assumed  that  infection  from  the  bovine 
bacillus  rarely,  if  ever,  took  place  in  man. 

In  substantiation  of  the  first  proposition  he  placed  upon  record  the 
results  of  experiments  conducted  during  the  |ifei-edinu  two  years  by 
Schiitz  and  himself.  Nineteen  younn  cattle  lice  iVoin  i  ui.enulo-is  were 
subjected  to  prolonged  periods  of  inhalation  exposure,  lo  lo(]il  infection, 
and  to  direct  inoculation  by  human  bacilli.  These  animals,  after  six  to 
eight  months,  presented  no  trace  of  tuberculous  lesion  at  autopsy.     The 


28  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

same  attempts  with  bovine  bacilli  were  attended  with  constitutional 
sj'mptoms  within  one  week,  and  extensive  tuberculous  changes  were 
found  at  autopsy  two  or  three  months  later.  Similar  experiments  with 
human  and  bovine  bacilli  yielded  like  results  in  swine,  asses,  sheep,  and 
goats.  In  support  of  his  second  proposition  he  pointed  to  the  large  num- 
ber of  bovine  bacilli  contained  in  butter  and  milk  and  to  the  alleged  rarity 
of  primary  intestinal  tuberculosis  in  infants.  He  cited  statistical  ob- 
servations concerning  the  infrequency  of  this  condition,  although  little 
children  especially  were  recognized  to  be  exposed  and  predisposed  to 
infection.  But  ten  cases  were  observed  during  a  periotl  of  five  years 
in  the  Charite  Hospital  in  Berlin.  Baginsky  was  reported  as  never 
having  observed,  out  of  933  cases,  an  instance  of  intestinal  tuberculosis 
without  simultaneous  involvement  of  lungs  and  glands.  Biedert  was 
quoted  as  having  seen  but  sixteen  cases  out  of  a  total  of  3104  autop- 
sies upon  tuberculous  children.  Baumgarten,  a  few  months  after 
Koch's  address,  indorsed  the  position  assumed  with  reference  to  the 
non-transmissibilit}'  of  the  two  diseases,  and  made,  as  he  stated,  an 
important  contribution  to  the  subject  by  recalling  the  experiments  of 
Rokitansky.  The  latter,  firm  in  the  belief  of  the  unity  of  human  and 
bovine  tuberculosis,  had  inoculated  with  bacilli  from  cattle  a  number 
of  patients  suffering  from  incurable  malignant  diseases.  This  was 
done  in  the  hope  of  establishing  an  antagonism  between  the  tubercle 
bacilli  and  the  bacteria  of  previous  infection,  thus  affording  a  cure 
to  otherwise  hopeless  invalids.  Large  numbers  of  tubercle  bacilli  of 
bovine  origin  were  injected  without  noticeable  results  other  than  small 
localized  abscesses  at  the  points  of  inoculation.  The  autopsies  upon 
these  patients  were  performed  by  Baumgarten,  and  in  spite  of  critical 
macroscopic  and  microscopic  examination  of  the  tissues  and  glandular 
structures,  no  evidence  of  tuberculous  infection  was  discovered.  While 
thus  espousing  Koch's  teaching  on  account  of  the  failure  of  inoculation 
experiments  both  upon  man  and  animals,  and  while  denying  any  especial 
danger  to  man  from  the  consumption  of  bovine  products,  Baumgarten 
insisted,  however,  upon  certain  strong  points  of  resemblance  between 
the  two  diseases.  He  referred  to  the  histologic  identity  of  the  tuber- 
culous lesions  in  man  and  cattle  as  established  by  Schiippel,  and  pointed 
to  the  similar  degenerative  changes  in  the  two  conditions.  He  cited 
the  production  of  acute  miliary  tuberculosis  in  cattle  after  infection 
with  bovine  tuberculosis,  precisely  as  in  man  with  the  human  bacillus. 
He  further  called  attention  to  the  same  reaction  in  cattle  as  in  man 
following  the  injection  of  tuberculin  derived  from  human  bacilli.  These 
various  facts,  supplemented  by  a  supposed  morphologic  and  cultural 
identity  of  the  two  liacilli,  were  deemed  sufficient  by  Baumgarten  to 
establish  a  close  similarity  of  human  and  bovine  tuberculosis,  notwith- 
standing the  disparity  shown  by  inoculation  experiments. 

Virchow.  in  an  addre.ss  delivered  before  the  Medical  Society  of 
Berlin  in  July,  1901,  one  or  two  days  following  Koch's  communication 
in  London,  referred  to  his  previous  statements  in  1863  regarding  the 
non-unity  of  human  and  bovine  tuberculosis.  He  said:  "I  was  not 
surprised  to  hear  that  Professor  Koch  had  finally  convinced  himself 
that  they  were  two  different  things,  even  after  my  old  thesis  containing 
the  same  statement  has  been  regarded  by  the  Koch  school  for  a  con- 
siderable length  of  time  with  a  certain  contempt,  and  I  have  borne  their 
judgment  with  patience.     I  certainly  have  never  understood  how  any 


THE    RELATION    OF    HUMAN    AND   BOVINE    BACILLI  29 

one  could  maintain  that  the  two  were  identical."  He  further  empha- 
sized the  existence  of  true  pathologic  tubercle  as  a  sine  qua  non  for  genu- 
ine tuberculosis,  insisting  that  the  bovine  infection  was  an  example  of 
bacteriologic  disease  rather  than  of  typical  pathologic  tissue  change. 
Virchow  did  not  refrain,  however,  from  disparaging  Koch's  contention 
concerning  the  rarity  of  primary  intestinal  tuberculosis.  He  called 
attention  to  the  existence  of  unusual  intestinal  and  peritoneal  lesions 
observed  at  the  Charite,  exhibiting  growths  peculiar  to  the  so-called 
"perle  disease"  of  cattle,  but  scarcely  attributable  to  human  bacilli. 

In  view  of  these  somewhat  contradictory  statements  from  many 
preeminent  European  authorities,  based  upon  the  results  of  careful 
study  and  experimentation,  a  renewed  impetus  was  given  to  a  study  of 
the  subject.  Commis,sions  were  appointed  in  Germany  and  Great 
Britain  to  investigate  this  matter,  and  a  vast  amount  of  exhaustive 
research  was  conducted  in  the  United  States.  The  German  authors, 
as  a  rule,  were  inclined  to  support  Koch's  views,  although  several  dis- 
senting opinions  were  expres.sed,  notably  those  of  Behring  and  Dungern. 
Weber  recently  has  reported  observations  of  interest  and  value  made 
by  the  Berlin  Board  of  Health.  The  liovine  bacillus  was  found  fifteen 
times  in  the  cervical  glands  of  chDdren.  He  asserts  that  this  vaiiety 
occurs  almost  exclusively  in  the  young,  and  that  a  marked  tendency 
toward  spontaneous  cure  is  noted.  In  almost  all  instances  I'epoiled 
the  children  were  under  seven  years  of  age.  He  has  been  able  to  dis- 
cover no  instance  of  transmission  of  the  bovine  infection  from  one 
human  being  to  another,  and  is  constrained  to  believe  that  the  tlanger 
of  infection  to  man  from  bovine  tuberculosis  is  in.significant  as  compared 
with  that  from  the  human  variety. 

Raw,  although  recently  announcing  his  conviction  as  to  the  dissimi- 
larity of  human  and  bovine  bacilli,  yet  attributes  a  large  amount  of 
tuberculo.sis  in  children  to  the  introduction  of  the  latter.  He  calls 
attention  to  the  conspicuous  differences  between  the  clinical  manifes- 
tations of  pulmonary  phthisis  and  other  tuberculous  affections,  and  em- 
phasizes an  apparent  antagonism  between  pulmonary  and  surgical  tuber- 
culosis. He  asserts  that  children  who  have  suffered  from  strumous 
glands,  spinal  caries,  tuberculous  joints,  and  lupus  are  immune  to 
phthisis  pulmonalis.  and,  conversely,  points  to  the  infrequency  of  gro.ss 
tuberculous  lesions  in  cases  of  pulmonary  tuberculosis.  Upon  the  basis 
of  these  clinical  differences,  and  the  fact  that  surgical  tuberculosis  is 
essentially  a  disease  of  chilillKiiHl,  he  concludes  that  the  characteristic 
divergence  of  losioiis  is  ]>r('Slml|)ti^•o  cxidciicc  of  di  -iinil.-ii-  bacilli.  Re- 
lying upon  clinic:!!  ;iiid  nuldpsy  iil  iscn:il  idii .  H.^cilici-  «ith  certain 
inferences  from  aiialony.  he  sulnnits  ihr  pl■ovi^io|lal  o]iiiiion  that  the 
enlarged  lymphatic  lilaiuls  of  the  iicc!<.  I  nl  •(a(ai|oii-'  pri'iioiiitis,  tuber- 
culous l)ones  ami  joints,  t  uIhtcuIous  mciiin^it  i~.  ami  lupus  are  occa- 
sioned by  the  invest  ion  of  bovine  liacilli,  while  the  origin  of  pulmonary 
phthisis  is  attiibutcil  lo  the  introduction  of  the  human  bacillus. 

The  British  Conum-sion,  appointed  after  the  close  of  the  Inter- 
national Antitut>errulous  Conference  in  London  in  1901,  was  composed 
of  the  renowned  Sir  Michael  Foster,  chairman,  and  Professors  Wood- 
head,  Martin,  Boyce,  and  MacFadyean.  Their  first  report,  published  in 
1904,  expressed  quite  clearly  a  disinclination  to  accept  the  teaching  of 
Koch  as  to  the  non-intercommunicability  of  human  and  bovine  tuber- 
culosis.    Numerous  experiments  were  undertaken  by  the  commissioners 


30  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

to  determine  primarily  whether  the  disease  in  animals  and  man  was  one 
and  the  same,  and  whether  infection  could  take  place  from  one  to  the 
other.  Investigations  were  made  by  a  comparison  of  the  lesions  produced 
in  cattle  upon  the  introduction  of  bacilli  of  human  and  bovine  origin. 
Similar  experiments  were  performed  upon  the  anthropoid  ape,  an  animal 
nearly  related  to  man,  and  al.so  upon  guinea-pigs,  rabbits,  goats,  dogs, 
cats,  and  rats.  Bacterial  cultures  of  bovine  bacilli,  as  well  as  emulsions 
of  tuberculous  lesions  from  thirty  cases  of  bovine  tuberculosis,  were  in- 
jected into  strong,  healthy  animals  previously  tested  with  tuberculin. 
In  some  cases  the  introduction  was  made  subcutaneously,  in  many,  into 
the  veins  of  the  udder,  and  in  others,  by  means  of  the  food.  In  numerous 
cases  of  subcutaneous  injection  it  was  found  that  the  proximal  lymphatic 
glands  soon  became  involved,  that  fever  developed  about  the  twelfth 
day,  and  that  death  took  place  from  the  twentieth  to  the  fiftieth  day. 
At  autopsy  there  was  found  general  tuberculosis  of  the  glands  and  serous 
membranes,  the  lungs,  liver,  and  kidneys.  In  some  cases,  however, 
there  were  merely  local  symptoms  of  but  temporary  duration  without 
especial  pathologic  change  at  autopsy.  These  cUvergent  results  were 
explained  by  the  introduction  of  varying  quantities  of  infective 
matter  and  by  a  possible  difference  in  the  resisting  powers  of  the 
animals.  It  was  found,  also,  that  those  having  been  subjected  to 
udder  injection  exhibited  a  considerable  variation  in  the  character 
of  the  resulting  changes.  In  some  cases  death  supervened  quickly, 
with  postmortem  evidences  of  extensive  tuberculous  disease.  Others 
displayed  but  local  evidences  of  infection,  which  subsided  after  a  short 
time.  Five  calves  out  of  six  sucking  from  infected  udders  showed 
signs  of  local  and  general  tuberculosis,  as  did  monkeys,  pigs,  rabbits, 
guinea-pigs,  and  goats  after  inoculation  or  feeding  with  bovine  bacilli. 
More  resistance  was  shown  by  dogs,  cats,  and  rats.  Sharply  de- 
fined differences  were  displayed  in  the  virulence  of  tubercle  bacilli 
taken  from  fourteen  cases  of  human  tuberculosis  and  injected  into 
animals.  In  one  group  general  tuberculous  changes  were  produced 
after  inoculation  of  cows  and  the  other  lower  animals  employed  in  pre- 
vious experiments  with  bovine  bacilh.  In  this  group  there  was  but 
slight  variation  noticed  in  the  virulence  of  the  two  types  of  bacilli.  In 
another  group,  however,  bacilli  or  tuberculous  material  taken  from  forty 
ca.ses  of  human  tuberculosis  produced  merely  a  slight  local  inflammatory 
change,  with  swelling  of  the  nearest  lymphatic  glands.  In  some  of 
these  cases  the  injection  of  large  quantities  of  infective  material  did  not 
produce  any  evidence  of  a  general  advancing  tuberculosis,  either  in 
cattle,  cats,  or  dogs,  although  there  were  several  instances  of  slight  non- 
progressive organic  involvement.  Monkeys,  as  a  rule,  were  foimd  to 
be  non-resistant.  The  Commission  attributed  the  divei'gent  results  of 
these  experiments  to  differences  of  animal  resistance  and  to  variations 
in  the  virulence  of  the  inoculated  material.  The  report  of  the  Com- 
mission is  summed  up  as  follows: 

"There  can  be  no  doubt  that  in  a  certain  number  of  cases  the  tuber- 
culo-sis  occurring  in  the  human  subject,  especially  in  children,  is  the  direct 
result  of  the  introduction  into  the  human  bod}'  of  the  bacillus  of  boxnne 
tuberculo.sis,  and  there  also  can  be  no  doubt  that,  in  the  majority,  at 
least,  of  these  cases,  the  bacillus  is  introduced  through  cow's  milk. 
Cow's  milk  containing  tubercle  bacillus  is  clearly  the  cause  of  tuberculo- 
sis.    A  very  considerable  amount  of  disease  and  loss  of  life,  especially 


THE    RELATION'    OF    HUMAN    AND   BOVINE    BACILLI  31 

among  the  young,  must  be  attributed  to  the  consumption  of  cow's  milk 
containing  tubercle  bacilli.  The  presence  of  tubercle  bacilli  in  cow's  milk 
can  be  detected,  though  with  some  difficulty,  if  the  proper  means  be 
adopted,  and  such  milk  ought  never  to  be  used  as  food.  There  is  far  le.ss 
difficulty  in  recognizing  clinically  that  a  cow  is  distinctly  suffering  from 
tuberculo.sis,  in  which  case  she  may  yield  tuberculous  milk.  The  milk 
coming  from  such  a  cow  ought  not  to  form  a  part  of  human  food,  and, 
indeed,  ought  not  to  be  used  as  food  at  all." 

These  conclusions  are  directly  in  accord  with  the  opinions  expressed 
by  Drs.  Schroeder  and  Cotton  in  this  country.  Their  researches  are 
reported  in  detail  in  "  The  Bulletin  of  the  Bureau  of  Animal  Industry  of 
the  United  States  Department  of  Agriculture,' '  recently  issued.  They 
even  affirm  that  a  tuberculous  cow  constitutes  an  element  of  much 
greater  danger  to  the  health  of  the  community  than  a  human  consump- 
tive. Considerations  pertaining  to  this  subject  will  be  later  discussed 
at  some  length.  In  America,  since  the  promulgation  of  Koch's  doc- 
trine, much  interest  has  been  attached  to  an  investigation  of  the  inter- 
communicability  of  human  and  bovine  tuberculosis. 

Ravenel  called  attention  to  the  experiments  conducted  in  1901 
by  Chauveau,  who  finally  succeeded  in  infecting  cattle  with  bacilli  of 
human  origin.  Well-markerl  tiiberculous  proce.sses  were  found  in  three 
cows  following  the  inti-o(hicti(in  <if  infoctinus  iii.itcrial  with  the  food  and 
by  means  of  intravcinius  iuicctidii.  I'lKin  Mil hhi aiieous  inoculation 
of  seven  animals,  however,  in  no  case  wa,s  tliere  oljtained  evidence  of 
general  infection.  Crookshank,  in  the  same  year,  after  inoculation 
of  human  tuberculous  material  into  the  peritoneal  cavity  of  a  calf, 
reported  a  positive  result,  as  did  Thomassen  in  1901,  aftei'  inocu- 
lation of  the  anterior  chamber  of  the  eye.  Successful  innculations 
were  conducted  by  Arloing  in  1901  and  de  Jong  ami  Xmard  in  1902. 
Martin  produced  infection  of  four  calves  out  <>f  si\  li\-  int  loduciim  tu- 
bercle bacilli  with  the  food.  In  1902  Kaxcncl  iciMnicI  llic  ivs\ilts  of 
his  own  investigations,  dating  back  four  years.  <  )f  Imircahcs  iimculated 
with  human  bacilli  into  the  peritoneal  ca\-ity.  one  exhiliitcd  pidiMniuced 
illness  during  life  and  three  showed  at  autopsy  unmistakalilc  c\idciices 
of  tuberculous  infection.  An  experiment  of  vast  iin]i(iiiaiicc  ccm- 
ducted  by  him  was  the  inoculation  of  two  calves  with  a  cull  are  olj- 
tained from  the  mesenteric  gland  of  a  child  whose  death  resulted  fiom 
tuberculous  meningitis,  but  who  exhibited  clear  evidence  of  a  primary 
intestinal  lesion,  presumably  of  bovine  origin.  The  utmost  virulence 
characterized  the  infection  in  each  instance,  and  a  c(iiirhi,-i(iii  a-^  to 
the  probable  bovine  type  of  the  bacillus  appeals  ciniiienilx  laiiunal. 
He  later  published  the  reports  of  four  ca.ses  (if  accident.al  iiifcition  of 
the  hands  with  bovine  bacilli,  reference  to  which  will  be  made  in  con- 
nection with  the  skin  as  a  channel  of  infection. 

S.  von  Ruck,  in  an  exhaustive  article  upon  the  intercommunica- 
bility  of  human  and  bovine  tuberculosis,  takes  exception  to  much  of 
the  inoculation  evidence  adduced  by  various  observers  in  refutation 
of  Koch's  position.  He  points  to  possible  sources  of  error  and  believes 
the  results  are  subject  to  considerable  criticism.  He  refers  to  the  work 
of  Waldenburg,  Fox,  Panum,  Wyss,  Cohnheim,  Frankel,  and  other  con- 
temporaries of  Villemin,  who  severally  succeeded  in  producing  pseudo- 
tuberculosis after  inoculation  with  non-infective  material,  or  with  tuber- 
culous matter  rendered  innocuous  by  boiling  and  prolonged  submersion 


62  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

in  alcohol.  The  substances  injected  consisted  of  metallic  mercury, 
coal-dust,  fresh  blood  of  guinea-pigs,  paper,  lint,  rubber,  and  pieces  of 
sponge.  It  is  probable,  however,  as  pointed  out  by  several  observers 
at  that  time,  to  which  reference  has  been  made,  that  the  opposition 
to  Villemin  resulted  from  imperfections  of  technic  in  the  conduction 
of  experiments,  and  that  actual  tuberculous  material  was  introduced 
without  the  knowledge  of  the  operator.  It  cannot  be  possible  that 
such  sources  of  error  could  obtain  with  experienced  and  skilful  experi- 
menters at  the  present  time,  especially  when  one  considers  the  attain- 
ments of  those  who  have  conducted  recent  investigations.  It  is  no 
reflection,  however,  upon  the  merits  of  the  earlier  observers  to  ascribe 
their  results  to  obvious  possibilities  of  error  in  their  attempts  to  transmit 
artificial  human  tuberculosis  to  cattle.  Although  Prudden,  Hodenpyl, 
and  others  have  shown  that  the  intravenous  injection  of  dead  bacilli  ma_v 
be  followed  by  characteristic  tuberculous  lesions,  this,  contrary  to  the 
assumption  of  von  Ruck,  affords  in  itself  no  convincing  argument  preju- 
dicial to  the  reliability  of  recent  inoculation  experiments.  Attention 
has  been  called  to  the  contention  of  Baumgarten  concerning  the  impro- 
priety of  intravenous  or  intraperitoneal  injection,  and  the  greater  ad- 
vantage of  subcutaneous  inoculation.  This  is  alleged  upon  the  ground 
that  the  latter  offers  opportunity  to  study  the  n<lvance  of  the  infection 
through  the  lymphatics,  and  avoids  the  jxissiLilit}-  nf  confusion  result- 
ing from  embolism  and  consequent  comi)li(;itini;  pathologic  processes, 
simulating  tuberculosis  of  the  peritoneum.  Upon  tliis  basis  von  Ruck 
criticizes  many  of  the  recent  inoculation  experiments,  charging  erroneous 
conclusions  in  case  of  several  intravenous  injections,  suggesting  possi- 
bilities of  incorrect  intcrprotation  of  intraperitoneal  inoculation,  and 
emphasizing  the  neuativc  ivswli-  of  a  cDH-iilcialjle  number  of  subcuta- 
neous injections.  It  i-  pcitiiifiit,  li(i\\f\i'i-,  t(i  call  attention  to  the  fact, 
even  if  other  considerations  l)e  waiveil,  that  such  objections  scarcely  can 
obtain  in  case  of  inoculation  into  the  anterior  chamber  of  the  eye,  which 
procedure  has  been  attended  in  many  instances  with  a  positive  local  and 
general  infection.  Furthermore,  the  very  authority  cited  by  von  Ruck 
in  partial  support  of  his  view,  i.  e.,  Baumgarten,  has  been  placed  on 
record  as  maintaining  strongly  the  close  similarity  of  human  and  bovine 
tuberculosis  despite  his  conception,  in  accord  with  Koch,  of  an  actual 
resistance  of  cattle  to  infection  with  human  bacilli.  From  the  evidence 
presented  it  is  reasonably  safe  to  assert  that  while  bovine  bacilli  un- 
doubtedly possess  a  much  greater  degree  of  pathogenic  vindence  for 
cattle  and  other  animals  than  the  human  variety,  the  latter  are  not 
shown  to  be  innocuous  upon  injection.  It  may  be  assumed  that  human 
tuberculosis  in  occasional  instances  and  under  favorable  conditions  can 
be  transmitted  to  cattle. 

The  doctrine  of  Koch  that  the  bovine  infection  is  rarely  transmitted 
to  human  beings  has  been  said  to  rest  tipnn  the  alleged  infrequency  of 
primary  intestinal  tuberculosis  in  childivn.  (lcs])ite  the  ingestion  of  liovine 
bacilU  in  milk,  butter,  and  other  dairy  pi(»lnits.  The  fallacy  of  this  as- 
sumption is  shown  by  the  demonsi  laMc  pi(»if  of  infection  through  the 
inte.stinal  tract  without  the  .slightc-t  iiaci'  ni'  mucous  membrane  altera- 
tion. Calmette  and  Guerin  have  rcniii  1\-  conducted  elaliorate  investiga- 
tions as  to  the  frequency  of  mfection  thiough  the  alimentary  tract 
without  visible  lesion  of  the  intestine.  On  account  of  the  prevalence 
of  pulmonary  tuberculosis  it  has  been  assumed  that  the  respiratory  tract 


THE   RELATION    OF    HUMAN    AND   BOVINE    BACILLI  33 

represents  a  much  traversed  port  of  entry  for  the  tubercle  bacilli.  Pre- 
vious views  as  to  the  infrequency  of  invasion  through  the  alimentary 
canal  suggested  by  the  rarity  of  primary  intestinal  tuberculosis  have 
been  subjected  to  much  modification  as  a  result  of  their  experiments. 

Theobald  Smith  and  others  have  called  attention  to  the  frequent 
primary  involvement  of  the  peribronchial  lymph-nodes  in  tuberculous 
cattle.  Calmette,  Guerin,  and  Delearde  introduced  tuberculous  material 
into  the  stomachs  of  animals  by  means  of  the  esophageal  tube  in  order 
to  avoid  the  possible  inhalation  of  bacilli.  After  a  period  of  thirty  to 
forty-five  days  the  peribronchial  lymph-nodes  were  found  to  have  become 
infected  through  the  medium  of  bacilli-laden  leukocytes.  A  single  in- 
fected feeding  to  calves  resulted  in  the  retention  of  the  microorganisms 
for  a  time  in  the  mesenteric  glands,  but  subsequently  they  were  con- 
veyed to  the  mediastinal  and  retropharyngeal  glands,  in  some  instances 
even  after  a  small  dose.  The  mesenteric  glands  presented  no  macro- 
scopic evidence  of  disease,  but  when  injected  into  guinea-pigs,  produced 
typical  tuberculous  lesions.  Calmette  and  Guerin  also  reported  several 
positive  results  of  inoculation  when  use  was  made  of  the  apparently 
normal  mesenteric  glands  of  children  who  exhibited  no  trace  of  tuber- 
-culosis,  similar  experiments  having  been  conducted  by  Pizzini,  Loomis, 
and  others,  with  like  results.  In  the  event  of  continuous  feeding  with 
tuberculous  material,  the  bacilli  were  found  to  enter  the  thoracic  duct 
and  pulmonary  artery  through  the  lymphatic  circulation.  Various  in- 
halation procedures  were  employed,  and  bacilli  were  introduced  directly 
into  the  trachea,  but  the  resulting  infection  was  uniformly  slight  and 
attributable  chiefly  to  the  .swallowing  of  infected  mucus  or  saliva.  A 
noteworthy  feature  of  these  experiments  was  the  priority  of  mesen- 
teric glandular  involvement  over  that  of  the  respiratory  system.  A 
paramount  importance  was  ascribed  to  infection  through  the  intestine, 
and  it  was  assumed  that  the  tuberculous  material  was  conveyed  to  the 
alimentary  tract  largely  through  the  mUk  of  infected  cows,  and  as  a 
result  of  food  contaminated  by  human  bacilli.  Nicolas  and  Dorcas 
have  shown  that  smears  from  the  thoracic  duct  of  fasting  dogs  taken 
three  hours  after  an  infected  meal  contained  tubercle  bacilli.  If  the 
above  observations  be  accepted  for  their  face  value,  any  arguments 
relative  to  the  rarity  of  infection  through  the  intestine  based  upon  the 
absence  of  local  lesions  at  once  falls  to  the  ground.  In  this  connection 
the  thought  is  suggested,  however,  that,  as  cows  are  ruminating  animals, 
especial  opportunity  for  infection  through  the  fauces,  tonsils,  and 
pharynx  to  the  retropiiaiynirc-il  d.-inds  is  .■ilTdidcd  by  their  habit  of 
■chewing  the  cud.  It  is  ipiilc  |inssililc  id  (■nii(ci\c  in  this  manner  of  the 
ready  entrance  of  the  bacilli  indi  llic  lymphatics  and  their  direct  convey- 
ance to  the  rctr(ipliaiyn,<j,cal  l\ni|)h-niH|cs. 

Despite  ini]»iitant  iiml  radicioi  \  (■\idence  advanced  by  several  in- 
vestigators, notably  Smith,  tin-  tact  lemains  that  in  the  light  of  the 
experiments  of  Calmette  and  Guerin  it  may  be  assumed  that  the  intestine 
constitutes  at  least  one  of  the  very  important  routes  of  invasion  by  the 
bacillus.  No  proof  has  been  adduced  as  to  the  infrequency  of  food  con- 
tamination by  bovine  bacilli,  while  the  facilities  for  such  inlcctiDii  appear 
worthy  of  consideration.  Thus  any  contention  to  the  cITcii  llial  infce- 
tion  through  milk  or  other  food-products  can  be  assumed  (inly  w  lien  tlie 
intestinal  or  mesenteric  glands  are  first  involved  is  unwarranted.  Medi- 
cal literature,  however,  is  replete  with  reports  of  primary  intestinal 

3 


34  ETIOLOGY    AXD    PATHOLOGIC    ANATOMY 

lesions  in  chUdren,  and  of  infection  traceable  more  or  less  directly  to 
milk  from  tuberculous  cows. 

In  striking  contrast  to  the  statistical  observations  previously  cited 
in  support  of  the  alleged  rarity  of  primary  intestinal  lesions,  and  in  oppo- 
sition to  the  reports  of  Bovaird,  Northrup,  and  a  few  European  path- 
ologists, are  the  conclusions  of  Councilman,  Mallory,  Pearce,  Holt,  Carr, 
Guthrie,  Still,  and  Shennan.  The  autopsy  fincUngs  in  little  children 
reveal  a  primary  involvement  of  the  intestine  in  a  proportion  varying 
from  17  per  cent,  to  37  per  cent.  These  much  quoted  statistics  are  too 
familiar  to  the  average  reader  to  warrant  an  enumeration  of  their 
details.  It  is,  of  course,  impossible  to  assert  that  infection  in  all 
cases  was  due  to  the  bovine  bacillus,  as  unusual  exposure  to  the 
human  bacillus  is  afforded  to  infants.  Jensen  and  Fibiger  have 
made  elaborate  researches  concerning  the  frequency  of  primary  tuber- 
culosis of  the  intestine.  A  third  report  of  their  observations  has  been 
presented  recently.  Two  cases  are  recorded  of  primary  tuberculous 
lesions  of  the  intestine  in  little  children  fed  with  milk  from  tuberculous 
cows.  In  one  a  striking  feature  with  the  onset  of  the  symptoms  was  the 
simultaneous  development  of  a  local  tuberculous  lesion  upon  the  udder 
of  a  cow.  Inoculation  of  bacilli  from  these  children  into  calves  and 
rabbits,  animals  notoriously  susceptible  to  bovine  cultures  and  resistant 
to  those  of  human  origin,  was  attended  with  evidences  of  an  exceedingly 
virulent  infection.  The  above  observers  have  collated  and  analyzed 
many  cases  from  the  literature  of  the  subject,  and  affirm  that  the  sup- 
posed rarity  of  primary  intestinal  tuberculosis,  especially  among  chil- 
dren, is  more  or  less  mythical.  While  numerous  writers  have  recorded 
instances  of  apparent  bovine  infection  transmitted  to  children  through 
the  food,  evidence  is  not  lacking  to  demonstrate  an  equal,  if  not  greater, 
frequency  of  infection  among  infants  unaccustomed  to  other  than 
mother's  milk.  Smith  declares  that  if  either  the  human  or  the  bovine 
bacillus  was  completely  eradicated  from  the  world,  the  other  would 
continue  to  induce  the  disease.  Von  Ruck  very  aptly  has  called  atten- 
tion to  an  increased  prevalence  of  infantile  tuberculosis  in  countries 
where  the  children  are  almost  invariably  breast  fed.  He  cites  the 
higher  death-rate  of  children  in  Sweden  and  Roumania  (Babes).  Green- 
land (Heymann),  China  (Cobb),  where  cow's  milk  rarelj'  is  consumed 
by  children,  in  contrast  to  the  diminished  mortality  from  tuberculosis 
in  England,  where  artificial  feeding  is  common. 

Raw,  upon  the  other  hand,  instituted  inquiries  in  a  great  many 
foreign  countries  with  a  view  to  establishing  a  comparison  between  the 
distribution  of  pulmonary  consumption  and  surgical  tuberculosis  in 
various  localities.  He  reported  that  while  pulmonary  phthisis  is  rife 
even  in  countries  where  milk  is  not  consumed  by  children,  yet  other 
forms  of  tuberculosis  are  extremely  rare.  Mayo  has  called  attention 
to  the  relative  infrequency  of  pulmonary  tuberculosis  in  an  agricul- 
tural community,  although  all  forms  of  surgical  infections  abound,  and 
ascribes  the  prevalence  of  the  latter  varieties  to  the  ingestion  of  the 
bovine  bacilli  contained  in  uncooked  milk. 

The  testimony  from  Japan  is  qiute  conflicting.  Kitasato  has  been 
quoted  by  several  writers  to  the  effect  that  tuberculosis  in  cattle  did  not 
exist  in  Japan,  and  that  milk  was  very  little  used  as  an  article  of  food  for 
children,  although  the  disease  actively  flourished  among  the  inhabitants. 
This  statement  has  been  corroborated  by  Asyama  (Schoenborn),  but 


THE    RELATION    OF    HUMAN    AND   BOVINE    BACILLI  35 

Shiga  dates  the  development  of  tuberculosis  in  Japan  to  the  importation 
of  cattle  in  1875. 

Behring's  theory  as  to  the  extreme  frequency  of  human  infection 
through  tuberculous  milk,  though  of  much  interest  in  this  connection, 
is  more  properly  a  subject  for  later  consideration.  The  comparatively 
recent  discovery  in  milk  and  butter  of  pseudo tubercle  bacilli  is  perhaps 
explanatory  to  some  extent  of  the  not  uncommon  innocuous  effect  of 
ingesting  supposedly  infected  dairy  products.  These  microorganisms  do 
not  surrender  their  primary  stain  to  inorganic  acids,  yet  are  incapable 
of  producing  tuberculous  tissue  change. 

The  morphologic  and  cultural  differences  between  human  and  bovine 
bacilli  have  been  pointed  out  very  clearly  by  Theobald  Smith  and 
Ravenel.  A  comparison  of  their  reports  disclo.sed  such  uniformity  of 
conclusions  as  to  admit  of  no  doubt  concei-ning  their  accuracy.  Smith 
stated:  "The  distinguishing  characteristics  in  the  early  stages  are:  (1) 
The  short,  straight,  somewhat  plump,  rod-like  form  of  the  bovine  bacillus 
as  contrasted  with  the  long,  more  slender,  and  slightly  curved  form  of 
the  sputum  or  pulmonary  type  of  the  human  bacillus.  (2)  The  much 
greater  tendency  of  the  human  bacillus  to  cohere  in  compact  colonies  or 
curved  outlines."  Ravenel  reported  that  in  early  generations  the  length 
of  the  bovine  is  but  little  more  than  double  its  breadth,  and  agreed  with 
Smith  as  to  the  characteristics  of  growth  and  the  general  disposition  of 
the  human  bacilli  in  dense  colonies.  Smith  has  very  recently  called 
attention  to  the  more  abundant  capsule  of  the  human  than  the  Imvine 
bacOlus.  He  finds  that  cold  carbol-fuchsiii  is  al.-oilMd  less  ic:i(lil\  by 
the  bacillus  of  human  origin.  Bovine  bacilli  iiia\  cxliiliit  :i  /cmc  aiound 
each  rod  in  which  no  stain  has  taken  place,  but  the  capsules  are  ill-defined 
in  human  bacilli  on  account  of  the  close  colonization.  Behring  has 
emphasized  the  fact  that  the  toxin  from  the  l)()\ine  liacillus  is  identical 
with  that  of  the  human  tubercle  bacillus.  De  Schweinitz  was  of  the 
same  opinion,  as  no  difference  was  discovered  in  the  reaction  following 
the  administration  of  tuberculin  derived  from  human  and  bovine  sources. 
In  view  of  the  vast  array  of  clinical,  pathologic,  and  bacteriologic  evi- 
dence bearing  directly  upon  the  relation  of  the  human  to  the  bovine 
bacillus,  the  following  conclusions  appear  inevitable: 

1.  That  recognizable  difforonces  do  exist  in  their  morphologic  and 
cultural  attributes,  but  that  these  aic  not  of  such  a  nature  as  to  establish 
a  fundamental  divergence  in  the  (liai.ictcr  of  the  two  microorganisms. 

2.  That  the  lack  of  perfect  identity  in  these  separate  varieties  of  the 
same  bacterial  organism  is  occasioned  by  essential  modifications  of  the 
host. 

3.  That  the  pathogenic  virulence  of  the  bovine  form  is  much  greater 
among  animals  than  is  the  human  bacillus. 

4.  That  a  correspondingly  increased  activity  and  pathogenic  power 
of  the  bovine  bacillus  in  comparison  with  the  human  thus  far  has  not 
been  demonstrated  to  obtain  in  human  beings. 

5.  That,  on  the  contrary,  among  individuals  a  greater  virulence 
attaches  to  the  bacillus  of  human  origin  than  to  the  bovine. 

6.  That  the  practical  dangers  of  infection  from  the  bacillus  of  cattle 
are  sufficiently  real  to  justify  no  abatement  of  legislative,  municipal, 
and  indivifiual  measures  to  suppre.ss  the  disease  among  domestic  animals 
and  afford  protection  to  the  human  race. 


36  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 


CHAPTER   IV 
THE  CONGENITAL   METHOD  OF   INFECTION 

The  natural  Imljitat  of  the  tubercle  bacillus  is  the  living  human  or 
animal  organism.  Therein  is  provided  a  suitable  medium  with  favorable 
conditions  for  growth  and  development.  Although  enabled  to  preserve 
its  vitality  for  considerable  perioils  outside  the  body,  especially  if  not 
exposed  to  direct  sunlight,  it  is,  nevertheless,  incapable  of  multiplication 
save  within  the  host.  Through  a  long  process  of  reciprocal  adaptation 
there  has  evolved  an  extraordinary  parasitism  on  the  part  of  the  bacillus 
and  an  almost  universal  tolerance  or  receptivity  to  its  presence  by  man. 
Both  the  bacillus  and  the  living  animal  tissues  having  become  more  or 
less  habituated  to  this  relation,  a  tendency  toward  a  state  of  stable 
equilibrium  between  host  and  parasite  is  established. 

To  maintain  this  relationship  and  preserve  the  existence  of  the  mi- 
crobe there  must  be  afforded,  as  Theobald  Smith  has  pointed  out,  read}' 
means  of  entrance  to  the  living  organism  and  avenues  of  departure.  It 
is  apparent  that  the  human  and  animal  body  is  both  the  pnal  objective 
point  and  the  source  of  all  tubercle  bacilli  dissemination.  In  this  dual 
relation  of  receptor  and  donor  of  infection  there  exists  the  very  essence 
of  the  problem  of  practical  prophylaxis  relating  to  a  disease  which  has 
quietly  assumed  the  proportions  of  a  scourge. 

It  is  necessary,  therefore,  to  attain  a  clear  understanding  concern- 
ing the  various  channels  of  entrance  of  the  bacillus  into  the  human  body, 
the  means  of  exit,  and  the  extent  and  manner  of  distribution. 

The  route  of  invasion  of  the  liacillus  has  been  for  years  the  subject 
of  a  spirited  controversy  between  the  advocates  of  several  widely  differ- 
ing theories,  concerning  the  correctness  of  which  there  has  been  adduced 
in  each  instance  much  experimental  and  clinical  evidence.  It  is  clear 
that,  from  a  practical  standpoint,  the  determination  of  the  preci.se 
manner  in  which  the  bacillus  is  introduced  into  the  system  is  of  infinitely 
less  importance  than  the  recognition  of  effective  means  to  prevent  its 
distribution  after  leaving  the  body.  While  a  paramount  interest 
attaches  to  the  control  of  the  bacillary  egress  from  the  bod}*,  consider- 
able importance  relates  to  the  most  frequented  ports  of  entry. 

The  principal  avenues  of  infection  to  which  attention  is  directed  are — 
(1)  The  congenital  route  of  transmission;  (2)  the  respiratory  tract; 
(3)  the  alimentary  canal. 

Infection  by  inoculation  and  the  various  methods  of  invasion  of 
special  organs  will  be  discussed  in  some  detail  in  connection,  respec- 
tively, with  tuberculosis  of  the  lymphatic  glands  (cervical,  mediastinal, 
mesenteric),  the  bones  and  joints,  the  entire  alimentary  tract,  the 
genito-urinarj'  apparatus,  the  serous  membranes  (pleural,  pericardial, 
and  peritoneal),  the  skin,  the  larynx,  ear,  and  nose. 

HEREDITARY  TRANSMISSION 

Congenital  tuberculosis,  though  known  to  be  a  demonstrable  pos- 
sibility, is  relatively  infrequent.  In  former  years  the  influence  of  her- 
edity as  an  etiologic  factor  was  supposed  to  be  of  transcendent  impor- 


THE    CONGENITAL   METHOD    OF   INFECTION  37 

tance,  some  maintaining  the  existence  of  fetal  tuberculosis,  and  others, 
merely  an  inherent  predisposition  to  the  disease  at  birth.  For  many 
years  the  inheritance  idea  was  accorded  a  general  acceptance.  It  early 
took  deep  root  in  the  mechcal  and  popular  minds  on  account  of  the 
common  development  of  consumption  among  the  children  of  tuber- 
culous parents.  Belief  in  the  hereditary  transmission  of  tuberculosis 
was  also  fostered  by  the  pronoimced  nutritive  disturbance  frequently 
observed  in  the  offspring  of  consumptive  parents.  Despite  the  absence 
of  tubercle  bacilli  in  the  tissues  or  of  definite  anatomic  lesions  character- 
istic of  tuberculosis,  the  numerous  evidences  of  defective  development 
in  infancy  corresponded  closely  to  some  of  the  clinical  types  of  tuber- 
culous infection.  In  early  childhood  the  persisting  enlargement  of 
lymphatic  glands,  hypertrophied  tonsils  and  adenoids,  anemia,  coarse- 
ness of  features,  slow  dentition,  and  retardation  of  growth  were  thought 
to  constitute  reliable  data  in  substantiation  of  an  inherited  tuberculous 
infection.  Although  the  pendulum  of  medical  opinion  has  since  swung 
violently  toward  the  doctrine  of  contagion,  Baumgarten  and  his  fol- 
lowers remain  ardent  advocates  of  the  theory  relating  to  direct  trans- 
mission of  the  bacilli  in  utero.  In  support  of  their  position  may  be 
stated:  (1)  The  clinical  and  pathologic  evidence  pertaining  to  isolated 
cases  of  congenital  tuberculosis;  (2)  the  results  of  experimentation  in 
animals;  (3)  the  known  latency  of  tubercle  bacilli  in  the  tissues  of  the 
body;  (4)  the  development  of  the  disease  at  a  very  early  age;  (5)  the 
origin  of  the  tuberculous  process  in  portions  of  the  body  not  readily 
accessible  to  infection  from  without;  (6)  the  frequency  of  tuberculosis 
among  the  children  of  consumptive  parents. 

Before  proceeding  to  a  consideration  of  the  several  arguments  bear- 
ing upon  hereditary  transmission  it  is  well  to  review  the  manner  in  which 
congenital  tuberculosis  is  possible  of  development.  The  primary 
source  of  the  infection  must  be  traced  to  the  spermatic  fluid,  the  ovum, 
or  the  placental  circulation.  Transmission  through  the  medium  of  the 
spermatic  fluid,  though  not  susceptible  of  complete  negative  demonstra- 
tion, is,  however,  clearly  improbable.  To  permit  of  this  occurrence  it 
must  be  assumed  that  tubercle  bacilli  are  not  only  present  in  the  semen, 
but  also  in  the  nuclear  material  of  the  spermatozoon  and  in  that  par- 
ticular portion  with  which  the  ovum  is  fecundated.  Thus  the  element 
of  probability  is  strongly  opposed  to  a  chance  infection,  even  if  bacilli 
exist  in  the  seminal  fluid.  It  is  known,  however,  that  this  does  not 
occur  save  in  exceptional  instances  of  tuberculosis  of  the  seminal  vesi- 
cles, testicles,  and  epididymis.  As  flicso  idiiditious  are  often  associated 
with  sterility  from  mechanical  causes,  ii  i,~  .ill  ilic  more  difficult  to  con- 
ceive of  bacillary  transmission  to  the  oxiun  tliiou.H;h  the  semen.  In 
advanced  urogenital  tuberculosis  the  occaMuuaJ  presence  of  bacilli  in 
the  spermatic  .secretion  is  not  denied,  yef  iic.  proof  has  been  pre.sented 
to  substantiate  the  claim  that  they  ai-e  iiresent  in  the  semen  of  pul- 
monary invalids  devoid  of  such  local  infection.  Several  foreign  observers 
have  reported  that  bacilli  were  discovered  in  the  testicles,  epididymes, 
prostates,  and  seminal  vesicles  of  patients  who  had  died  of  pulmonary 
tuberculosis,  and  that  portions  of  these  organs  were  found  infective  to 
lower  animals.  This,  however,  affords  no  evidence  in  favor  of  the  prob- 
able transmission  of  congenital  tuberculosis  by  these  individuals  during 
life.  It  is  obviously  unsafe  to  submit  for  comparison  pathologic  data 
referable  to  the  testicles  of  a  corpse  and  the  sexual  and  procreative  pos- 


38  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

sibilities  of  consumptives  who  are  yet  alive.  It  is  to  be  noted,  also, 
that  numerous  investigations  by  careful  observers  of  the  genito-urinary 
organs  of  phthisical  patients  after  death  have  failed  to  disclose  evidence 
of  local  tuberculous  infection.  Instances  of  primary  infection  of  the 
female  genital  organs  are  sufficiently  rare  to  cast  much  doubt  upon  the 
spermatic  method  of  transmitting  tuberculosis. 

E.xperimental  work  of  some  importance  has  been  conducted  by 
Gartner,  Cornet,  and  more  recently  by  Friedman.  Gartner,  in  a  series 
of  laboratory  tests,  found,  after  the  injection  of  tubercle  bacilli  into 
the  testicles  of  rabbits  and  guinea-pigs,  that  the  artificially  ejaculated 
semen  not  infrequently  contained  bacilli,  but  that  this  was  incapable 
of  transmitting  tuberculosis  to  their  young.  The  examination,  both 
before  and  after  birth,  of  many  offspring  of  these  animals  having  infected 
semen  yielded  in  each  instance  a  negative  result.  Cornet  was  similarly 
unsuccessful  in  like  experiments,  though,  with  Giirtiier,  he  observed  the 
development  of  tuberculosis  in  some  of  the  females  as  a  result  of  genital 
infection.  Friedman,  however,  by  injecting  an  emidsion  of  tubercle 
bacilli  into  the  vaginas  of  rabbits  quickly  following  coitus,  found  bacilli  in 
the  fetal  organs  at  the  end  of  six  days.  James  assumes  that  this  experi- 
ment is  of  striking  value  as  afforcUng  conclusive  evidence  concerning  the 
possibility  of  transmission  through  the  semen.  This  does  not  appear  to 
be  quite  a  logical  deduction,  as  even  in  the  case  cited  the  bacilli  were  not 
introduced  into  the  ovum  through  and  by  virtue  of  the  seminal  fluid, 
but  rather  were  injected  in  large  numbers  by  external  means.  The 
presence  of  bacilli  in  no  wise  could  be  attributable  to  the  seminal  fluid, 
nor  is  the  experiment  analogous  to  the  physiologic  function  of  the 
genital  organs. 

But  little  evidence  has  been  advanced  concerning  the  possible  trans- 
mission of  the  infection  by  the  ovum.  Baumgarten,  after  an  artificial 
fecundation  of  the  ovum  of  a  rabbit  with  infected  seminal  fluid,  was 
successful  in  finding  bacilli  in  the  ovum.  Up  to  the  time  of  his  observa- 
tion no  bacilli  had  been  found  in  the  ovary.  Various  experiments  liave 
been  conducted  by  him  and  Maffucci  in  the  inoculation  of  hen's  eggs  with 
avian  bacilli.  These  do  not  appear  at  all  relevant,  however,  to  a  con- 
sideration of  the  congenital  transmission  of  tuberculosis  in  man. 

By  far  the  most  frequent  method  of  intra-uterine  infection  is 
through  the  placental  circulation.  Even  this  is  exceedingly  rare, 
either  in  man  or  animals,  and  but  few  well-authenticated  cases 
have  been  reported.  Considerable  confusion  has  arisen  from  the 
fact  that  infants  born  of  mothers  in  advanced  phthisis  are  sub- 
jected to  exceptional  opportunities  for  infection  shortly  after  birth. 
A  special  predisposition  to  infection  exi.sts  in  such  cases,  and  tuberculo- 
sis may  develop  with  wonderful  rapidity.  It  is  important,  therefore, 
to  remove  all  doubt  as  to  the  possible  extra-uterine  origin  of  the  disease 
before  assuming  its  inclusion  in  the  category  of  congenital  tuberculosis. 
Obviously,  in  the  great  majority  of  cases  this  is  attended  with  much 
difficulty.  No  uncertainty,  however,  is  involved  in  observations  rela- 
ting to  fetal  and  placental  examinations,  instances  of  unquestionable 
tuberculosis  of  the.se  tissues  being  recorded.  Well-defined  tuberculous 
changes  have  been  reported  in  the  lungs,  liver,  spleen,  pleura,  and  peri- 
toneum of  infants  dying  a  few  days  after  birth,  and  in  the  placenta  of 
mothers  who  were  in  the  last  stages  of  consumption.  It  has  been  re- 
ported that  despite  the  normal  appearances  of  fetal  organs  and  of  the 


THE   CONGENITAL   METHOD   OF   INFECTION  39 

placenta,  positive  results  have  followed  the  inoculation  of  animals  with 
portions  of  these  tissues.  The  same  is  true  of  injections  of  blood  from 
the  placental  circulation.  In  contracUstinction  to  these  observations  a 
large  number  of  similar  experiments  have  been  performed  without  the 
production  of  tuberculous  infection  in  lower  animals.  Portions  of  the 
organs  of  still-born  infants  from  tuberculous  mothers  have  been  injected 
repeatedly  into  the  peritoneal  cavity  of  guinea-pigs  and  rabbits  without 
success.  Small  animals  during  pregnancy  have  been  infected  virulently 
with  human  tubercle  bacilli  and  the  progeny  in  only  a  small  proportion 
of  cases  were  found  to  be  tuberculous.  Instances  of  reported  congenital 
tuberculosis  have  appeared  to  be  more  frequent  in  animals  than  in  human 
beings.  In  view  of  the  separate  placental  and  maternal  circulations  it 
may  be  assumed  that  the  transmission  of  tubercle  bacilli  from  a  con- 
sumptive mother  to  the  fetus  in  utero  cannot  occur  save  as  a  result  of 
such  pathologic  change  in  the  structural  relations  as  will  permit  an 
abnormal  communication  between  the  two.  It  is  comprehended  that 
this  may  take  place  either  with  or  without  localized  tulaerculous  proc- 
esses in  the  placenta.  It  is  probalile,  moreo\'er,  that  the  toxins  which 
have  accumulated  in  the  placenta  may  Ije  transmitted  to  the  fetus  with- 
out the  bacUli.  Bossi  believes  that  the  toxins  thus  entering  the  fetal 
circulation  are  largely  responsible  for  the  physical  weakness  and  defecti\-e 
development  of  many  infants,  having  diminished  resistance  to  tubercu- 
lous infection.  In  his  experience  as  an  obstetrician  he  has  had  oppor- 
tunity to  examine  and  subject  to  animal  inoculation  a  large  number  of 
fetal  organs,  as  well  as  placental  tissues,  from  ])a.tients  in  advanced 
phthisis,  and  seldom  has  he  found  in\()lveni(-nt  of  these  structures. 

Irrespective  of  the  clinical  and  experimental  evidence  adduced  to  sub- 
stantiate the  possibility  of  congenital  tuberculosis,  it  is  well  to  consider 
the  inferential  arguments  which  have  been  presented  as  suggestive  of 
intra-uterine  infection.  The  prolonged  latency  of  bacillary  infection,  par- 
ticularly in  the  glandulai-  tissues,  without  producing  acti\c  s\iiiptiims 
until  a  remote  period  nf  (liininislicd  resistance,  is  often  rcuaiiliil  :is  mch- 
cative  of  a  congenital  in^■asll)Il.  The  1)asis  for  belief  in  latent  lilanchilar 
infection  is  the  recognition  of  tubercle  bacilli  in  bronchial  and  mesenteric 
lymph-nodes  which  are  macroscopicallx'  iiiiad.  A  more  detailed  refer- 
ence to  these  findings  will  be  made  iii  (Minncction  with  glandular  tuber- 
culofsis.  The  reports  of  Pizzini  and  others,  to  which  reference  is  made 
elsewhere,  demonstrate  conclusively  the  not  infrequent  presence  of 
bacilli  in  these  structures,  apparently  without  unfavorable  consequences. 
Portions  of  glands  taken  from  patients  who  have  died  of  other  diseases 
without  displaying  traces  of  tuberculous  infection  have  been  injected  into 
animals  with  positive  results.  Rabinowitch  has  recently  reported  an 
interesting  and  instructive  e.xperience  in  connection  with  the  mediastinal 
glands  of  patients  clinically  free  from  tuberculosis.  The  glands  had  been 
the  seat  of  inflammatory  processes,  evidently  resulting  from  the  initial 
infection,  and  had  undergone  svd^sequently  a  degenerative  change, 
becoming  so  calcified  as  to  present  the  hardness  of  stone.  Inoculation  of 
lower  animals,  however,  resulted  in  the  development  of  definite  tuber- 
culous infection.  In  these  cases  the  period  of  latency  of  the  bacilli  must 
have  been  very  prolonged.  Such  an  observation  is  opposed  directly  to 
the  view  of  Cornet,  who,  although  admitting  the  existence  of  tuberculous 
glands  without  macroscopic  change,  argues  against  a  so-called  latency  of 
any  considerable  duration.     He  disputes  a  disproportionate  longevity  of 


40  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

the  bacillus  in  glands  as  compaietl  \\  ith  tuberculous  processes  in  general. 
He  asserts  that  there  is  imi  >uiri.ii'iit  proof  that  tubercle  bacilli  may 
retain  their  virulence  for  ye;ii>  ami  \  it  remain  in  the  body  as  innocuous 
non-multiplying  parasites  without  encapsulation.  He  evidently  does 
not  believe  that  their  prolonged  sojourn  in  the  glandular  tissues,  even 
if  true,  can  be  considered  an  effective  argument  in  favor  of  their  intra- 
uterine origin.  Despite  his  protests,  there  appear  to  be  ample  clinical 
and  experimental  ilata  in  support  of  a  belief  in  latent  infections  of 
very  prolonged  duration.  Huebner  has  recently  reported  that  tubercle 
bacilli  are  agglutinated  by  the  blood  of  many  non-tuberculous  children. 
This  at  least  may  be  regarded  as  provisional  evidence  concerning  the 
existence  of  latent  foci  of  infection.  The  blood  from  the  umbilical  cord 
was  reported  never  to  agglutinate  the  bacilli.  The  lowest  percentage  of 
agglutination  was  found  in  children  entirely  devoid  of  clinical  evidences 
of  tuberculosis,  and  the  highest,  in  those  presenting  suspicion  of  a  scrofu- 
lous taint.  A  high  percentage  was  also  found  in  those  with  hypertrophied 
tonsils  and  adenoids.  Salge  has  reported  that  the  lilood  of  babies  vmder 
one  year  of  age  without  suspicion  of  tuberculo.^is  agglutinates  tubercle 
bacilli  in  12.5  per  cent,  of  cases.  Schkarin  recorils  a  po.sitive  result  of  the 
agglutination  test  in  21.4  per  cent,  of  non-tuberculous  children.  From 
these  reports  it  must  be  admitted  that  latent  foci  of  tuberculous  infection 
are  much  more  common  in  little  children  than  is  generally  supposed.  It 
hardly  foUows,  however,  that  this  should  be  regarded  as  proof  of  heredi- 
tary transmission,  although  the  evidence,  as  to  an  increased  inherited 
predisposition,  is  quite  conclusive. 

The  frequency  of  the  disease  at  an  early  age,  however,  is  irrefutable 
and  is  responsible  in  a  measure  for  Baumgarten's  contention.  Mortality 
statistics  are  extremely  high,  particularly  after  the  last  quarter  of  the 
first  year,  and  increase  progressively  with  each  year  of  life  up  to  the  age  of 
fifteen  or  sixteen.  It  must  be  rememljered  that  infants  are  remarkably 
susceptible  to  tuberculous  infection,  and  that,  as  a  rule,  the  course  is 
excessively  rapid.  It  would  appear  that  but  little  resistance  is  offered 
to  the  onward  progress  of  the  bacillus.  It  is  well  known  that  the  tis.sues 
are  much  more  deUcate  in  structure  and  more  easily  permeable  by  bacilli 
than  in  adults,  and  that  the  lymphatic  spaces  are  proportionately  larger, 
offering  less  obstruction  to  the  advance  of  the  infection.  It  .seems  diffi- 
cult to  reconcile  these  established  facts  with  a  theory  of  the  congenital 
transmis.sion  of  the  microorganism  as  well  as  of  the  toxins.  If  the  latter 
be  conceded  to  restrict  development  and  impair  resistance,  there  could 
scarcely  continue  an  indefinite  period  of  bacillary  infection  without 
clinical  evidence  of  the  di.sease.  That  latent  tuberculous  foci  do  exist 
in  many  cases  is  beyond  (Uspute,  but  it  may  be  questioned  properly  if 
the  sources  of  infection  in  such  ca.ses  are  not  extra-uterine  rather  than 
congenital.  This  hypothesis  is  the  more  reasonalile  in  view  of  the  nega- 
tive evidence  previously  presented  regarding  the  infrequency  of  tuber- 
culosis in  utero.  In  this  manner  an  explanation  is  afforded  as  to  the 
existence  of  latent  infection  in  children  which  is  impossible  of  rational 
interpretation  from  an  acceptance  of  the  doctrine  of  hereditary  trans- 
mission. Baumgarten,  in  his  advocacy  of  the  inheritance  idea,  has 
adduced  two  arguments  to  substantiate  his  position,  which  are  evi- 
dently opposed  to  each  other.  He  advances  the  theory  of  a  wide- 
spread latency,  and,  at  the  same  time,  points  to  alarming  statistics 
of  infantile  death  from  tuberculo.sis.     The  former  is  explainable  only 


THE    CONGENITAL   METHOD  OF   INFECTION  41 

upon  the  assumption  of  a  perfectly  established  defense  on  the  part 
of  an  organism  infected  prior  to  birth,  and  the  latter  upon  the  belief 
in  a  relatively  diminished  resistance  at  this  time  of  life.  Upon  the  other 
hand,  the  opponents  of  his  theory  can  easily  reconcile  the  existence  of 
latent  tuberculous  infection  in  some  children  to  their  relatively  increased 
powers  of  defense.  The  general  fi-ecpiency  of  the  disease  among  the  very 
young  may  be  explain(>(l  in  part  by  the  unusual  opportunities  for  extra- 
uterine infection  ari.-;inii  IVdiii  llir  almost  ubiquitous  distribution  of  the 
bacilli  and  the  peculiarly  iiie.spuusible  habits  characteristic  of  this  age. 
The  possible  sources  of  infection  at  this  time  of  life  are  almost  infinite, 
and  include  the  indiscriminate  fondling  by  tuberculous  individuals,  the 
contamination  of  milk  and  other  foods,  the  playing  upon  the  floor  or 
ground,  and  the  placing  of  miscellaneous  objects  in  the  mouth.  Con- 
siderations pertaining  to  the  early  infection  of  the  very  young  through  the 
alimentary  and  respiratory  tracts  will  be  reserved  for  later  discussion. 
That  these  channels  constitute  important  methods  of  infection  in  little 
children  who  are  born  healthy  is  impossible  of  controversion. 

The  fact  concerning  which  all  observers  agree  is  the  lamentably  high 
death-rate  in  infants  from  tuberculosis.  Botz  has  reported  2576  autopsies 
in  tuberculous  children,  of  which  27.8  per  cent,  died  the  first  year.  Other 
statistical  observations  of  a  similar  nature  will  be  given  in  connection 
with  glandular  tuberculosis.  Dietrich,  of  Berlin,  from  a  recent  analysis 
of  the  official  publications  of  the  Prussian  statistical  office,  reports  that 
"there  are  a  greater  number  of  actual  deaths  from  tuberculosis  in  the 
first  year  of  life  than  in  any  other  age  period."  He  further  states  that 
there  has  been  no  actual  decrease  in  the  number  of  deaths  from  tuber- 
culosis among  infants  in  Prussia  during  the  last  ninety  years.  While  the 
total  mortality  rate  in  that  country  from  tuberculosis  has  diminished 
one-third  during  the  past  thirty  years,  there  has  taken  place  curiously 
a  slight  increase  in  the  relative  number  of  deaths  from  this  disease  in  the 
first  year  of  life,  thus  showing  the  disproportion  existing  between  this 
and  other  age  periods.  Despite  the  active  educational  propaganda  now 
being  instituted  in  Prussia,  it  is  evident  that  a  pronounced  further 
diminution  of  the  total  death-rate  from  tuberculosis  can  be  secured 
only  by  effective  measures  to  limit  the  infection  in  infancy. 

Granche'r.  of  Paris,  after  an  examination  of  4226  school-children, 
has  recently  rei"iitiMl  tli;it  l.'i  per  cent,  were  fduml  tulici-cnldus,  tiocder, 
of  Berlin,  as  tlic  i-csulr  of  systematic  oxaininatinns.  fdund  a  suiprisnmly 
large  number  of  scliddl-rliildren  with  incipient  tidicrculdsis.  Chalnici-s, 
from  an  investigation  of  the  frequency  of  tuberculosis  among  the  chil- 
dren of  Glasgow,  reports  that  there  is  a  direct  relation  between  the 
prevalence  of  the  disease  and  the  increase  of  poverty.  School-children 
belonging  to  families  occupying  three  rooms  were  found  tuberculous  in 
3.4  per  cent,  of  all  cases;  if  two  rooms  were  used,  in  5.9  per  cent.,  but 
if  a  single  room,  in  8. -3  per  cent.  Upon  the  basis  of  all  available  evidence 
it  is  apparent  that  while  there  exists  an  alarming  prevalence  of  tubercu- 
losis among  children,  it  is  probably  attributable  to  external  conditions 
rather  than  to  intra-uterine  infection. 

The  localization  of  the  tuberculous  lesions  among  children  in  portions 
of  the  body  not  readilj'  accessible  to  external  infection  is  regarded 
by  some  as  suggestive  of  a  congenital  origin.  It  is  a  matter  of  clinical 
record  that  at  this  age  the  tubercle  bacilli  display  a  special  predilection 
for  the  invasion  of  glands,  bones,  and  joints.     Baumgarten  assumes  that 


42  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

such  localization  must  be  of  accidental  development  if  not  occasioned 
by  transmission  in  utero,  but  disclaims  the  former,  both  on  account  of 
its  improbability  and  on  the  ground  that  the  bacilli  always  produce 
some  lesion  at  the  point  of  entry.  It  is  well  known,  however,  that 
lymph-nodes  are  often  invaded  without  visible  lesion  at  the  infection 
atrium,  whether  this  be  the  tonsil  or  the  intestinal,  pharjTigeal.  and 
bronchial  mucosa.  In  a  large  number  of  cases  the  lymph-nodes  are 
the  primaiy  seat  of  the  tuberculous  process,  as  was  pointed  out  by 
Weigert  twenty  years  ago.  Harbitz  offers  corroborative  testimony  bj- 
referring  to  the  general  experience  of  pathologists  to  the  effect  that 
in  children  isolated  tuberculous  processes  are  rare  without  coincident  or 
prior  infection  of  the  bronchial  glands,  while  involvement  of  the  latter 
without  pulmonary  disease  is  not  infrequent.  Ribbert  and  Petruschky 
assert  that,  in  the  great  majority  of  cases,  tuberculosis  of  the  lymph- 
glands  in  children  antedates  infection  elsewhere.  Cnopp  has  shown 
that  147  children  out  of  298  victims  of  tuberculosis  had  bone  or  joint 
disease,  with  only  eight  of  these  exhibiting  infection  of  the  internal 
organs.  Numerous  statistical  reports  have  been  recorded  by  observers 
as  to  the  relative  frequency  in  children  of  tuberculous  processes  in 
various  portions  of  the  body.  Some  of  these  analyses  will  be  presented 
in  connection  with  tuberculosis  of  special  organs.  Upon  the  whole, 
it  is  noteworthy  that  the  lymphatic  glandular  structures  are  infected  in 
a  very  large  proportion  of  cases,  and  that  the  evidence  in  many 
instances  has  pointed  to  their  primary  involvement.  This,  however, 
cannot  be  considered  an  argument  in  favor  of  congenital  or  hema- 
togenous invasion.  Bacilli  are  known  to  penetrate  intact  mucous 
membranes  and  gain  entrance  to  proximal  glands  without  clinical 
evidence  of  disease.  Furthermore,  were  the  infection  derived  in  utero, 
it  would  be  supposed  that  the  liver  and  abdominal  viscera  should 
represent  the  primary  seat  of  the  disease,  but  these  organs  are  found 
involved  in  children  much  less  frequently  than  other  portions  of  the 
body. 

Perhaps  the  greatest  factor  in  the  evolution  of  the  belief  in  heredi- 
tary transmission  has  been  the  oft-noted  development  of  tuberculosis  in 
succeeding  generations.  Williams  records  a  family  predisposition  in 
48.4  per  cent,  out  of  1000  cases  of  consumption,  but  this  report  is  divested 
of  much  of  its  significance  when  he  adds  that  only  12  per  cent,  were 
parental  and  1  per  cent,  grandparent al.  the  remaining  34.4  per  cent, 
being  of  collateral  relation.  Solly  reported,  from  an  analysis  of  250 
cases,  28.8  per  cent,  with  a  history  of  parental  tuberculosis.  My  own 
observations,  based  upon  an  analysis  of  2070  ca.ses,  show  a  family  history 
of  tuberculosis  in  518.  or  25  per  cent.  Of  these.  398  were  instances  of 
parental  tuberculosis  and  94  of  grandparental.  In  26,  tuberculosis  had 
existed  both  in  parents  and  grandparents.  The  influence  of  heredity 
will  be  further  discussed  in  another  connection. 

A  noteworthy  feature  of  this  subject  is  the  infrequency  of  tuberculo- 
sis in  orphan  asylums,  in  which  one  would  naturally  expect  such  a  disease 
to  flourish  if  hereditary  influence  could  be  assigned  as  a  factor  of  especial 
etiologic  importance.  Congenital  tuberculosis,  though  an  admitted 
possibility,  must  be  regarded  as  of  rare  occurrence. 


INFECTION    BY    WAY   OF   THE    RESPIRATORY   TRACT 


CHAPTER  V 
INFECTION  BY  WAY  OF  THE  RESPIRATORY  TRACT 

The  inhalation  theory  of  tuberculous  infection  for  many  years  was 
accorded  a  quite  general  acceptance.  This  method  of  invasion  of  the 
body  by  the  tubercle  bacillus  appears  upon  superficial  thought  an 
eminently  simple  and  natural  explanation  of  localized  tuberculous  proc- 
esses within  the  lung.  So  reasonalile  and  apparently  satisfactory  a 
conviction  concerning  the  origin  of  the  disease  in  the  overwhelming 
majority  of  cases  has  been  rudely  disturbed  by  the  results  of  recent 
clinical,  pathologic,  and  experimental  investigation.  The  older  articles 
of  faith  regarding  this  mode  of  infection,  which  hitherto  have  been  sub- 
scribed to  almost  universally,  are  now  the  subject  of  an  animated  con- 
troversy. A  spirited  discussion  has  arisen  involving  the  frequency  of 
respiratory  infection.  Some,  as  a  result  of  considerable  research,  are 
inclined  to  repudiate  in  toto  the  inhalation  theory  of  bacillary  invasion 
and  to  accept  the  alimentary  tract  as  jiractically  the  exclusive  channel 
of  infection.  Others,  while  n(il  dciiyiim  ilic  siist:iiiicd  logic  of  newer 
anatomic  study,  embrace  the  Ijclicf  ili:ii  Imt  .-in  occnsidual  path  for  the 
bacillus  is  afforded  by  the  g:isti-(i-iii(csl  imil  (miimI  i>r  the  pharynx,  and 
insist  that  such  admission  detracts  nothing  from  the  tenability  of 
former  views.  They  still  adhere  to  the  opinion  that  the  respiratory 
tract  con.stitutes  the  principal  avenue  traversed  by  the  bacillus  in 
entering  the  body.  It  is  significant  that  even  among  the  advocates 
of  this  theory  some  violent  discussions  have  taken  place  with  reference 
to  the  precise  manner  in  which  the  microorganism  is  permitted  to  gain 
entrance  into  the  lungs  through  the  inspired  air. 

Cornet  was  an  early  exponent  of  the  doctrine  that  inhalation  infec- 
tion took  place  solely  through  the  conveyance  of  tubercle  bacilli  with 
contaminated  dust  to  the  terminal  bi-onchinlc-;  and  ah'cdli  li\'  nicaii^  of 
the  respii'atory  current.  The  es.sential  rlciiiciu  of  (laii'.ici  attaclnir^  \n 
tuberculous  sputum  was  regarded  as  attriliutaMc  ('\chisi\(l\  in  n-  (//</- 
ness.  Thus  the  presence  of  a  consumptive  as  a  source  of  |Mi^Ml,|r  cnnia- 
gion  to  others  was  believed  to  be  of  serious  import  only  in  ilic  ixcni  uf 
a  careless  cUsposal  and  drying  of  the  sputum.  The  piL-Mliilii  \  nf 
infection  through  the  ex|iirc(l  air  <if  a.  |iiiliii(iiiar\-  inxalid  was  lui  i  liw  itli 
discredited.  Fliigge  and  liis  |iupjls.  li(i\\i'\cr.  lia\'c  sIkiwh  (•(.nclusncly 
that  consumptives  in  the  act  of  coiiiiiiiiiu-,  and  cxi'ii  ul'  Idud  talkini;,  may 
dis.seminate  a  fine  spray  containing  tiiliciclc  liacilli.  The  il.Miiniisti-ation 
of  this  so-called  droplet  infection  is  i-cuardi'd  l.y  many  students  as  sug- 
gesting that  the  disease  is  transmitted  clnclly  tlii-(iui;h  moist  particles  of 
sputum.  Accordingly,  there  is  observed  in  some  quarters  a  tendency  to 
minimize  the  danger  of  transmission  of  tuberculosis  through  the  expec- 
toration. This,  however,  is  attended  by  a  corresponding  modification 
of  previous  opinions  relating  to  the  harmlessness  of  contact  with  careful 
consumptives.  This  later  belief  in  the  distribution  of  bacOli  through 
the  exhaled  air  has  fostered  an  exaggerated  notion  as  to  the  actual 
likelihood  of  infection  arising  from  close  proximitj'  to  pulmonary 
invalids. 


44  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

Before  discussim:  the  relative  merits  of  the  theories  of  transmission 
from  moist  :i]u\  ili  \  <initum  it  is  well  to  consider  the  general  proposition 
regartling  the  nsiuiatory  tract  as  an  avenue  of  tuberculous  infection, 
and  to  review  the  evidence  upon  which  may  be  based  an  assumption  as 
to  its  practical  importance.  The  arguments  which  have  been  adduced 
from  time  to  time  in  support  of  the  inhalation  method  of  infection  have 
been:  (1)  The  supposed  frequency  of  primary  pulmonary  involvement 
and  the  as-umcd  laiiiy  of  primary  intestinal  tuberculosis;  (2)  results 
of  experiments  uimhi  animals;  (3)  the  prevalence  of  consumption  among 
inmates  of  prisons  and  other  institutions;  (4)  the  repeated  coincidence 
of  the  ohsease  in  the  same  apartments  among  tenement  districts. 

These  affirmative  contentions  are  worthy  of  a  brief  consideration 
seriatim.  Supporters  of  the  inhalation  theory  have  pointed  to  the 
lungs  and  bronchial  glands  as  the  primary  foci  of  disease  in  the  vast 
majority  of  instances.  Complicating  lesions  in  other  parts  of  the  body 
were  recognized  as  more  recent  manifestations.  It  should  be  under- 
stood, however,  that  no  evidence  has  been  presented  to  suggest  that 
involvement  of  the  lungs  precedes  a  tubercle  deposit  in  the  bronchial 
glands.  On  the  contrary,  from  the  available  data  it  is  reasonable  to 
conclude  that  the  direct  reverse  is  the  case.  The  observations  of 
Weigert,  Harbitz,  Ribbert,  and  Petruschky  concerning  the  relation  of 
lymph-node  tuberculosis  to  pulmonary  involvement  have  been  referred 
to  in  the  previous  chapter.  Many  pathologists  agree  as  to  the  much 
greater  frequency  of  isolated  tuberculous  processes  in  bronchial  glands 
than  in  pulmonary  tissues.  Smith,  in  an  exhaustive  study  of  tuber- 
culosis in  cattle,  while  averring  that  the  usual  method  of  infection  is 
through  the  inhalation  of  tubercle  bacilli,  yet  states  that  the  chief  seat 
of  the  lesion  is  in  the  lymph-nodes.  In  many  herds  examined  by  him 
there  were  found  several  animals  exhibiting  no  tuberculous  lesions  what- 
ever save  lymph-node  cUsease.  In  one  herd  of  sixty  animals  fifty- 
three  were'  found  tuberculous,  and  of  this  number  twenty-seven  had 
well-defined  involvement  of  thoracic  lymph-nodes  without  pulmonary 
infection.  The  only  satisfactory  explanation  of  such  an  occurrence  in 
harmony  with  the  theory  of  inhalation  infection  is  a  primary  invasion 
of  these  structures  after  the  penetration  of  an  intact  mucous  mem- 
brane. This  Smith  readily  concedes,  but  believes  the  passage  of  bacilli 
to  the  mediastinal  glands  in  cattle  to  be  largely  through  the  tracheal 
or  bronchial  mucosa. 

While  it  is  true  that  an  involvement  of  certain  chains  of  lymphatics 
is  the  best  evidence  of  the  route  of  inva.sion  through  corresponding 
drainage  portals,  it  does  not  follow  that  infection  must  take  place  inva- 
riably through  such  channels.  There  is  abundant  evidence,  as  .shown 
in  prececUng  chapters,  to  the  efTect  that  tuberculosis  of  the  bronchial 
glands  readih'  occurs  without  the  resjiiratory  tract  serving  as  a  port  of 
entry.  Given  a  primary  tubercle  deposit  in  the  bronchial  glands,  it 
still  is  open  to  argument  if  such  invasion  be  attributable  in  general  to 
the  penetration  of  the  bacillus  through  the  mucous  memljrane  of  the 
respiratory  tract.  In  view  of  the  experience  of  Calmette  and  Guerin, 
previously  alluded  to,  and  the  recent  observations  of  Jonathan  Wright, 
Schlossman,  anil  Engel,  it  appears  perfectly  rational  to  assume  that  a 
most  important  lymphatic  pathwav  of  glandular  invasion  is  through 
the  pharynx  and  digestive  canal.  While  no  positive  evidence  has  been 
presented  to  substantiate  the  claim  of  an  invariable  invasion  through 


INFECTION    BY    WAY    OF   THE    RESPIRATORY   TRACT  45 

the  peribronchial  lymphatics,  it  has  been  demonstrated  definitely  that 
the  microorganism  may  gain  entrance  to  the  lymphatics  through  the 
pharynx  or  intestine  and  advance  to  the  glandular  structures  after  the 
lapse  of  a  few  hours.  On  the  other  hand,  considerable  negative  testi- 
mony has  been  adduced  with  reference  to  the  ingress  of  bacilli  to  the 
mediastinal  lymph-nodes  through  the  tracheal  and  bronchial  mucosa. 
The  old  assumption  that  the  bronchial  glands  were  infected  by  the 
passage  of  the  bacilli  to  those  structures  from  the  pulmonary  tissues  has 
been  generally  abandoned.  It  is  clear  that  the  lungs  may  become  the 
seat  of  tuberculous  infection  by  extension  lro7n  mediastinal  glands,  but 
whether  or  not  the  tubercle  bacilli  pass  in  large  numbers  through  the 
tracheal  and  bronchial  mucosa  to  the  proximal  lymphatic  glands  must 
remain  for  the  present  sub  judice.  Among  the  various  ((insidoiatidns 
having  a  negative  bearing  upon  this  subject  should  be  niciitiuiKNl  the 
futile  attempts  to  induce  pulmonary  tuberculosis  by  the  inject  ion  of 
large  quantities  of  bacilli  into  the  trachea,  and  the  other  inoculation 
experiments  of  Calmette  and  Guerin,  Nocard  and  Rbssignol.  On 
account  of  the  defensive  action  of  the  ciliated  epithelium  in  sweeping 
outward  offending  agents,  the  tubercle  bacilli  are  enabled  to  penetrate 
the  mucous  membrane  of  the  respiratory  tract  less  readily  than  that 
of  the  intestine.  It  has  been  claimed,  in  opposition,  that  the  presence 
of  fine  particles  of  dust  or  soot  in  the  bronchial  tubes  and  adjacent 
glands  is  convincing  evidence  of  the  ease  with  which  microorganisms 
may  be  similarly  conveyed.  As  the  terminal  bronchioles  and  alveoli 
are  equipped  less  formidably  with  cilia  than  the  large  and  medium-sized 
bronchi,  it  is  further  contended  that  those  particles  of  dust  and  bacteria 
which  eventually  gain  entrance  to  the  finer  bronchioles  are  ejected  with 
greater  difficulty  and  are  frequentl}-  permitted  in  these  portions  to 
obtain  a  lodging-place.  In  apparent  corroboration  of  these  theories 
Cornet  has  succeeded  in  producing  tuberculosis  in  guinea-pigs  by  ex- 
posing them  to  dried  tuberculous  sputum.  After  depositing  pulverized 
sputum  upon  a  carpet  in  a  room  of  76  cubic  meters,  he  placed  forty-eight 
guinea-pigs  at  various  distances  from  the  floor  and  obtained  character- 
istic le.sions  of  tuberculosis  in  forty-seven,  .■\lthough  Villemin,  Koch, 
Tappeiner,  andThaon  also  succeeded  in  producing  tul)erculosis  of  bron- 
chial glands  in  this  manner,  several  other  experimenters  failed  to  pro- 
duce infection  of  animals  through  inhalation  exposure.  Findel  has 
recently  demonstrated  that,  after  the  performance  of  tracheotomy  upon 
dogs  and  calves,  the  direct  inhalation  of  tubercle  bacilli  has  been  fol- 
lowed by  tuberculous  infection,  and  that  the  number  of  bacilli  necessary 
for  this  purpose  is  apparently  less  than  the  amount  required  to  accom- 
plish a  similar  result  through  the  digestive  tract.  It  is  apparent,  how- 
ever, that  quantitative  estimates  of  this  character,  based  upon  the 
injection  of  bacilli  directly  into  the  bronchi  of  tracheotomized  animals, 
are  scarcely  analogous  to  conditions  of  ordinary  respiration  and  are 
subject  to  many  possibilities  of  error.  Several  subsequent  attempts 
have  been  signally  unsuccessful.  Fliigge  a.sserts  that,  after  inhalation 
experiments,  the  inoculation  of  guinea-pigs  with  the  peripheric  portions 
of  the  lung  is  followed  by  the  development  of  tuberculous  infection, 
apparently  corroborating  a  belief  in  the  entrance  of  bacilli  to  the  finer 
bronchi  through  the  process  of  inhalation.  Although  the  possibility 
of  transmitting  tuberculosis  to  guinea-pigs  confined  in  small  cages 
and  compelled  to  inhale  an  atmosphere  laden  with  bacilli  is  admitted, 


46  ETIOLOGY    AND    PATHOLOGIC    AXATOMY 

it  does  not  follow  that  the  ordinarily  inspired  air  of  human  beings  con- 
veys tubercle  bacilli  to  the  finer  bronchioles,  there  to  penetrate  the 
mucosa.  In  man  the  sole  consideration  relates  to  the  accidental  intro- 
duction of  the  tubercle  bacillus  into  the  respiratory  tract,  which  as- 
suredly is  not  analogous  to  the  enforced  inhalation  of  innumerable 
bacilli  within  a  confined  space.  It  is  important  to  note  that  the  pul- 
monary infection  developing  in  animals  as  a  result  of  inhalation  experi- 
ments in  no  way  corresponds  to  the  development  of  tuberculosis  among 
human  beings.  It  is  not  without  significance  that  the  involvement 
thus  induced  in  animals  is  not  confined  to  the  apical  region,  but  is 
distributed  more  or  less  uniformly  over  the  entire  lung.  The  bacil- 
lary  content  of  the  air  is  assuredly  much  less  than  the  fragments  of 
impalpable  dust,  and  these,  as  a  rule,  do  not  proceed  unmolested  by 
the  cilia  to  the  ultimate  bronchi.  In  fact,  ^'an  Steenberge,  Grysez, 
and  others  have  failed  to  produce  pulmonary  anthracosis  in  animals 
by  the  compulsory  inhalation  of  air  saturated  with  soot,  and  have 
reached  conclusions  directly  opposed  to  those  of  Arnold,  Ponfick, 
Fleiner,  Muscatello,  and  other  previous  observers.  The  later  in- 
vestigators assume  that  this  condition  arises  from  the  swallowing 
of  particles  which  have  accumulated  within  the  nasopharynx  or  phar- 
ynx. They  assert  that,  upon  the  introduction  of  soot  into  the  stom- 
ach by  means  of  the  esophageal  tube,  thus  precluding  the  possibility 
of  inhalation  infection,  the  presence  of  these  particles  is  speedily  recog- 
nized in  the  mesenteric  and  mediastinal  glands.  In  connection  with 
this  experimental  data  Smith  introduces  an  element  of  uncertainty  by 
calling  attention  to  the  daily  ingestion  of  large  quantities  of  dirt  by 
domestic  animals.  While  the  mesenteric  and  mesocolic  lymphatic  nodes 
of  the  non-fastidious  pig  are  not  pigmented,  it  should  not  be  forgotten 
that  the  uncleanly  habits  of  this  animal  pertain  more  to  the  ingestion 
of  organic  filth  than  of  soot  or  non-organic  dust. 

In  long-standing  cases  of  pneumonokoniosis  the  presence  of  fine 
particles  of  dust  in  the  ultimate  bronchioles  lias  been  cited  by  some  as 
satisfactory  proof  of  the  entrance  of  tubercle  bacilli  into  these  por- 
tions of  the  respiratory  system  in  the  act  of  inhalation.  It  should  be 
remembered,  however,  that  such  condition  exists  only  from  greatly 
prolonged  and  excessive  exposure  to  a  mineral  dust  capable  of  exciting 
mechanical  disturbance.  For  its  production  there  are  associated  con- 
ditions of  atmospheric  vitiation,  an  excessive  amount  of  dampness,  a 
non-vitalized  and  confined  air  which  is  contaminated  by  smoke,  car- 
bon dioxid,  and  other  impurities. 

Again,  the  resulting  effects  are  not  incident  merely  to  the  inhalation 
of  dust.  There  often  develop  in  the  pulmonary  tissues  certain  struc- 
tural lesions,  permitting  in  themselves  a  degree  of  dust  retention  not 
possible  in  normal  conditions.  As  a  result  of  these  influences  there 
gradually  take  place  atrophic  and  nutritional  changes  in  the  mucous 
membranes,  with  a  destruction  of  the  superficial  epithelium.  As  the 
emphysema  and  chronic  bronchitis  progress,  opportunity  is  afforded 
for  the  accumulation  of  sooty  particles,  this  being,  however,  in  no  way 
analogous  to  ordinary  conditions  of  respiration.  It  is  of  further  interest 
to  note  that  anthracotic  conditions  are  not  restricted  necessarily  to 
apical  portions  of  the  lung,  as  often  asserted,  the  bases  being  involved 
quite  frequently  even  in  early  stages  (see  Plate  9).  For  the  above 
reasons  the  citation  bj'  Cornet  and  others  of  anthracosis  as  properly 


INFECTION  BY  WAY  OF  THE  RESPIRATORY  TRACT         47 

illustrative  of  the  mechanism  of  infection  with  tubercle  bacilli  is  obvi- 
ously inapt. 

The  usual  localization  of  tuberculous  lesions  at  the  apex  is  almost 
irrefutable  evidence  against  a  direct  inhalation  of  bacilli  to  the  remote 
bronchioles  and  alveoli.  If  such  were  the  manner  of  infection,  it  would 
be  reasonable  to  suppose  that  the  initial  tuberculous  processes  should 
be  distributed  more  or  less  uniformly  over  the  entire  pulmonary  area. 
Upon  the  assumption  of  immediate  inhalation  infection  without  the 
intervention  of  the  bronchial  glands  it  would  be  necessary,  as  formerly, 
to  attribute  the  circumscribed  lesions  at  the  apex  to  such  generalized 
and  indefinite  causes  as  are  expressed  in  the  convenient  phrase.  "  locus 
minoris  resistentia\"  If  impaired  respiratory  effort  and  diminished 
blood-supply  at  this  point  serve  as  a  satisfactory  explanation  con- 
cerning the  development  of  tuberculosis  in  a  single  portion  of  the  lung, 
despite  an  equal  and  proportionate  dis.semination  of  the  bacilli  through- 
out the  respiratory  tract,  it  is  difficult  to  account  for  the  essential  differ- 
ence in  the  localization  of  the  tuberculous  processes  in  childreh  and 
adults.  It  cannot  be  that  the  vicinity  of  the  hilus  and  the  base,  portions 
of  the  lung  notoriously  in-volved  in  children,  are  more  subject  at  that  age 
to  diminished  blood-supply  or  to  deficient  expansion.  Again,  if  such 
causes  are  conceded  to  exist  at  the  apex,  it  is  hard  to  understand  why 
lesions  at  that  point  are  prone  to  heal  with  more  or  less  rapidity.  It 
is  apparent  that  a  moi'e  rational  explanation  of  the  site  of  the  tuber- 
culous lesions  is  demanded  than  the  hypothesis  of  a  weakened  local 
resistance,  applying  to  a  single  portion  of  the  lung  in  adult  life, 
despite  a  generous  and  indiscriminating  distribution  of  bacilli,  with, 
however,  a  different  location  of  early  infection  in  children.  Upon 
the  basis  of  a  prior  infection  of  cervical  and  bronchial  glands,  irre- 
spective of  their  route  of  invasion,  whether  from  pharynx,  tonsil, 
trachea,  bronchial  tube,  or  intestine,  it  is  possible  to  reconcile  a 
unilateral  apical  extension  in  adults  by  means  of  the  blood-channels 
and  lymphatics.  Though  perhaps  not  susceptible  of  proof,  it  is  at 
least  a  reasonable  assumption  that  involvement  of  an  apex  may  pro- 
ceed in  some  instances  from  initial  inva.sion  of  cervical  glands,  and  this 
thought  is  in  line  with  the  results  of  some  clinical  observations.  In  the 
event  of  extension  from  bronchial  and  mesenteric  glands,  however, 
the  theory  of  Aufrecht  to  the  effect  that  the  bacilli  are  carried  through 
the  circulation  until  arrested  at  the  apex  in  the  terminal  pulmonary 
arteries  is  probablj^  true.  All  experiments  relating  to  the  feeding  of 
tuberculous  material  to  animals  and  the  subsequent  discovery  of  the 
tubercle  bacUli  in  the  thoracic  duct  and  veins,  as  previously  described, 
tend  to  substantiate  the  hematogenous  nature  of  the  apical  invasion. 
The  localization  of  the  process  in  children  is  undoubtedly  occasioned 
by  the  direct  lymphatic  infection  from  the  bronchial  glands.  The  lym- 
phatic spaces,  being  proportionately  larger  and  more  permeable  at  this 
age,  .should  permit  a  ready  exten.sion  to  the  contiguous  portions  of  lung. 
The  blood-stream  is  known  to  be  an  important  channel  for  the  trans- 
mission of  the  infection  to  the  apex  in  adults,  and  the  preponderance 
of  evidence  points  to  the  usual  route  of  tuberculous  invasion  at  all 
ages  through  the  blood-vessels  and  lymphatics.  It  would  appear,  how- 
ever, that  in  infants  the  conditions  are  such  as  greatly  to  facilitate  a 
direct  advance  of  bacilli  without  recourse  to  the  blood-stream. 

The  supposed  rarity  of  intestinal  tuberculosis,  which  formed  a  basic 


48  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

argument  in  favor  of  the  inhalation  theory,  has  proved  to  be  more  or 
less  incorrect.  Primary  intestinal  tuberculosis  is  known  to  be  more 
frequent  than  was  formerly  supposed,  and,  in  addition,  the  necessity 
of  local  lesions  at  the  point  of  entry  is  no  longer  recognized. 

On  account  of  the  exceptional  opportunity  offered  for  infection  the 
greater  prevalence  of  tuberculosis  among  the  inmates  of  institutions  has 
often  been  cited  to  support  the  view  of  inhalation  transmission.  It  is 
not  comprehended  why  an  increa.sed  danger  of  conveyance  is  referable 
entirely  to  infection  by  inhalation.  It  goes  without  saying  that 
added  possibilities  of  transmission  accrue  from  the  close  contact  of 
consumptives  with  a  large  number  of  people  within  a  relatively  con- 
fined space.  This  does  not  in  itself,  however,  involve  necessarily  the 
acceptance  of  a  single  method  of  infection  to  the  exclusion  of  all  others. 
From  the  manifest  opportunities  for  transmission,  together  with  a  com- 
bination of  conditions  inevitably  lessening  individual  resistance,  it  is 
apparent  that  infection  must  result  irrespective  of  the  precise  mode  of 
invasion.  The  citation  of  such  statistics,  therefore,  to  sustain  a  theory 
of  inhalation  infection  is  insufficient  for  this  purpose  unless  accompanied 
by  other  data  of  a  more  definite  nature.  While  tuberculosis  has  been 
found  to  flourish  in  prisons,  convents,  and  similar  institutions  in  which 
the  inmates  are  subjected  to  varying  degrees  of  close  seclusion,  it  is  also 
true  that  tlie  disease  has  developed  more  frequently  among  those  com- 
mitted to  solitary  confinement.  The  fact  that  amidst  such  surroundings 
the  more  restrictions  placed  upon  social  relations,  the  more  prevalent  the 
disease,  is  presumptive  evidence,  not  of  the  dangers  of  inhalation  infec- 
tion per  se,  but  rather  of  the  preponderating  influence  in  such  cases  of  an 
added  vulnerability  of  the  organism  to  an  infection  previously  latent. 
On  the  other  hand,  there  is  a  wide  divergence  in  statistical  observations 
pertaining  to  the  transmission  of  tuberculosis  to  nurses  and  attendants 
in  various  consumptive  hospitals.  The  Brompton  Hospital  for  Con- 
sumptives maii\-  times  has  been  referred  to  as  illustrative  of  the  com- 
paratively -liizlii  laiim  r  of  contagion.  The  same  is  true  of  Dettweiler's 
Sanatorium  at  I'alkciistein.  I  have  never  ob.served  the  occurrence 
of  tuberculosis  among  nurses  or  employes  in  any  of  the  institutions 
inhabited  by  pulmonary  invalids  in  Colorado,  but  not  infrequently  have 
become  cognizant  of  its  development  in  nur.ses  at  work  in  general 
hospitals  elsewhere.  It  would  appear  that  the  essential  element  in 
such  cases  is  the  individual  equation  and  the  nature  of  the  general 
environment,  rather  than  the  mere  matter  of  contact  with  consump- 
tives. 

The  same  method  of  reasoning  applies  in  large  measure  to  the  re- 
ported coincidence  of  tuberculosis  from  time  to  time  among  the  occupants 
of  the  same  apartments  in  the  closely  populated  tenement  districts  of 
large  cities.  The  distrilnition  of  consumption  in  a  single  ward  in  Phila- 
delphia during  a  period  of  twenty-five  years  has  been  studied  by  Flick, 
who  established  the  fact  that  the  di.sease  has  developed  repeatedly  among 
the  changing  inhabitants  of  the  same  abode.  His  researches  have  been 
generally  accepted  as  evidence  of  the  iniquitous  role  of  the  house  in  the 
transmission  of  tuberculosis.  Without  any  desire  to  detract  in  the 
slightest  degree  from  the  acknowledged  value  of  his  observations  or  to 
minimize  the  dangers  of  house  infection,  it  is  perhaps  fitting  to  inquire  if 
a  repetition  of  phthisis  in  the  same  apartments  is  sufficient  to  justify  an 
assumption  that  the  contaminated  dust  of  dwellings  constituted  the  all- 


INFECTION    BY    WAY    OF   THE    RESPIRATORY    TRACT  49 

important  source  of  infection.  More  than  one  case  of  tuberculosis  was 
found  to  have  occurred  in  33  per  cent,  of  the  infected  houses  in  this  ward 
during  a  quarter  of  a  century.  It  must  be  remembered  that  the  district 
was  populated  densely,  the  conditions  frequently  unsanitary,  and  the 
inhabitants,  as  a  rule,  unpossessed  of  marked  powers  of  resistance.  The 
majority  were  working-people  accustomed  to  long-continued  privation. 
Many  children,  as  well  as  adults,  were  compelled  to  undergo  strenuous 
hardship,  and  subjected  to  prolonged  hours  of  toil,  in  poorly  ventilated 
workshops,  only  to  return  at  the  end  of  the  day  to  overcrowded  and  ill- 
smelling  homes.  Without  adequate  instruction  as  to  necessary  precau- 
tions, without  sustaining  food,  or  proper  facilities  for  healthful  recre- 
ation, it  assuredly  appears  inevitable  that  consumption  would  be  widely 
prevalent  in  the  midst  of  such  surroundings.  In  view  of  these  unusual 
conditions  it  is  somewhat  remarkable  that  in  twenty-five  years  a  larger 
number  of  houses  did  not  chance  to  harbor  more  than  a  single  ca.se  of 
consumption.  It  is  questionable,  upon  the  face  of  the  returns,  if  the 
factor  of  supreme  importance  in  the  prevalence  of  the  disease  among 
succeeding  occupants  is  justly  attributable  in  these  cases  to  the  accumu- 
lation of  virulent  dust. 

Even  if  the  theorj'  of  inhalation  transmission  be  accepted,  it  has  been 
shown,  by  the  researches  of  Fliigge  and  others,  that  dry  sputum  dust 
does  not  constitute  the  sole  element  of  danger.  Fliigge  believes  that 
the  inspiration  of  an  atmosphere  containing  tubercle  bacilli  is  a  frequent 
means  of  infection,  but  takes  issue  with  Cornet  and  his  followers  as 
to  the  practical  degree  of  danger  arising  from  the  contamination  of 
air  with  bacilli-laden  dust.  It  is  admitted  by  Fliigge  and  his  pupils 
that  inhalation  infection  may  occasionally  develop  in  children,  though 
rarely  in  adults,  by  the  handling  of  handkerchiefs  and  clothing  upon 
which  sputum  has  been  deposited,  permitted  to  dry,  and  later  brought 
into  contact  with  the  mouth.  It  is  believed,  however,  that  the  pres- 
ence of  bacilli  in  the  air  after  separation  from  the  sputum  is  compara- 
tively infrequent.  It  would  seem  that  if  the  inhalation  theory  of  infec- 
tion is  conceded  to  be  an  important  mode  of  transmitting  the  disease,  it 
is  folly  to  deny  the  possibilities  of  contagion  arising  from  sputum  dust 
be  it  deposited  upon  the  floor,  rugs,  draperies,  clothing,  handkerchiefs, 
hands,  or  beard.  The  careless  and  indiscriminate  agitation  of  the  dust 
incident  to  the  ordinary  methods  of  house-cleaning  are  manifestly 
sufficient  to  effect  an  introduction  of  bacilli  with  the  inspired  air. 
Fliigge  originally  ascribed  the  principal  manner  of  infection  to  the 
inhalation  of  bacilli  contained  in  fine  particles  of  sputum  ejected 
from  the  mouth  of  consumptives  in  the  act  of  coughing  and  loud 
talking.  According  to  this  theory,  the  air  in  the  immediate  vicinity 
of  the  pulmonary  invalid  is  frccjucnlly  loaded  with  tubercle  bacilli. 
Numerous  experiments  were  cniKluctiMl  by  him  as  well  as  by  Fraenkel, 
Huebner,  Moeller,  Kirstein,  SclKirlTcr.  lleymann,  Hillier,  and  Ravenel. 
Huebner,  after  rinsing  the  mouth  with  a  suspension  in  water  of  the 
bacillus  prodigiosus,  placed  agar  plates  before  the  lips,  and  upon  counting 
loudly  up  to  375,  developed  119  colonies.  Seventeen  were  produced  by 
whispering  up  to  360,  while  41  colonies  were  obtained  by  counting  in 
an  ordinary  tone  up  to  550.  A  few  colonies  were  developed  by  removing 
the  plate  twenty  inches  from  the  mouth. 

Schoeffer  induced  lepers  with  well-defined  lesions  of  the  mouth  and 
throat  to  speak  for  ten  minutes  in  front  of  glass  slides  and  demonstrated 


50  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

the  presence  of  numerous  lepra  bacilli  which  had  been  projected  with 
fine  invisible  particles  from  the  mouth.  It  is  well  to  note  that  in 
these  experiments  numerous  bacteria  were  contained  within  the 
mouth  of  the  inchvidual.  This  condition,  however,  does  not  obtain, 
as  a  rule,  among  consumptives  save  in  the  very  act  of  coughing. 
Heymann  has  shown  that  the  droplets  ejected  at  such  a  time  are 
infective  to  guinea-pigs.  Fliigge  recently  made  experiments  upon 
thirty  patients  and  found  an  average  of  several  hundred  tubercle 
bacilli  suspended  in  the  air  within  a  radius  of  40  to  80  centimeters  from 
the  consumptive  within  a  period  of  thirty  minutes  after  the  act  of 
coughing.  In  some  of  these  cases  as  many  as  20,000  tubercle  bacilU 
were  estimated  to  be  present.  He  does  not  regard  the  zone  of  danger 
under  orcUnary  circumstances  to  exceed  three  feet  from  the  infected 
inchvidual,  but  believes  this  to  be  much  greater  during  violent  parox- 
ysms of  coughing.  Moeller  reports  the  fincUng  of  bacilli  upon  the  eye- 
glasses of  his  assistant,  as  weU  as  on  the  head-mirror  and  cheek,  after  an 
examination  of  patients  with  tuberculosis  of  the  larynx.  Sangman,  of 
Copenhagen,  disputes  the  practical  danger  of  such  infection  upon  the 
ground  that,  were  this  the  case,  lung  specialists  and  laryngologists 
would  become  the  subjects  of  tuberculous  disease  far  more  frequently 
than  at  present. 

During  a  physical  examination,  as  the  patient  is  frequently  urged 
to  cough  as  a  means  of  more  accurate  (Uagnosis,  it  would  appear  that 
the  physician  must  be  in  the  very  midst  of  an  atmosphere  capable 
of  producing  a  virulent  infection.  If  the  examiner,  in  the  course  of 
his  daily  work,  is  exposed  for  many  hours  to  droplet  infection,  it  must 
be  evident  that  the  prevalence  of  the  ihsease  among  phthisiothera- 
peutists  is  much  less  than  might  be  expected.  The  infrequency  of 
tuberculous  disease  among  laryngologists  is  partly  explained  by  the 
short  period  of  examination,  the  protection  afforded  by  glass  plates, 
and  bj'  the  inability  of  the  patient,  as  pointed  out  by  Ziesche,  to  secure 
any  forceful  intratracheal  pressure  with  the  epiglottis  open,  as  is  the 
case  during  examination.  The  practical  bearing  of  the  droplet  infec- 
tion, which  must  be  regarded  as  an  accepted  fact,  relates  not  only  to  the 
possibilities  of  inhalation  transmission,  but  as  well  to  the  added  danger 
of  food  contamination.  No  explanation  is  required  to  demonstrate  the 
ease  with  which  bacilli  may  be  deposited  upon  the  food  in  the  midst  of 
its  preparation  or  during  the  course  of  the  meal. 

While  it  does  not  appear  rational  to  deny  the  probability  of  the  occa- 
sional transmission  of  tuberculosis  through  the  process  of  inhalation,  a 
careful  review  of  the  evidence  fails  to  substantiate,  in  a  perfectly  satis- 
factory manner,  a  belief  in  the  respiratory  tract  as  the  principal  route 
of  bacillary  invasion. 

A  judicious  skepticism  is  never  prejudicial  to  an  honest,  scientific 
inquiry,  while  a  complete  acceptance  of  an  alluring  and  time-honored 
theory,  if  unsustained  by  positive  proof,  is  not  in  accord  with  the  funda- 
mental principles  of  modern  medicine.  It  is  important  to  bear  in  mind 
that  in  the  present  controversial  difference  of  opinion  the  practical 
consideration  relates  not  to  the  possibility  of  inhalation  or  of  ingestion 
infection,  but  rather  to  the  relative  frequency  and  importance  of  these 
two  channels  of  invasion.  Belief  in  frequent  infection  through  the 
respiratory  tract  does  not  constitute  per  se  any  justifiable  basis  for  the 
rejection  in  toto  of  the  digestive  canal  as  an  important  route  for  the 


INFECTION    THROUGH   THE    DIGESTIVE    TRACT  51 

tubercle  bacilli.  Pei-  contra,  absence  of  demonstrable  proof  that  inha- 
lation represents  the  principal  method  of  invasion  does  not  warrant  an 
assumption  as  to  the  predominating  importance  of  ingestion  tubercu- 
losis. It  is  submitted  that  a  critical  analysis  of  available  data  should 
be  inspired  by  no  preconceived  notions,  but  rather  conducted  in  a  spirit 
of  receptive  inquiry. 


CHAPTER   VI 
INFECTION  THROUGH  THE  DIGESTIVE  TRACT 

Irrespective  of  essential  differences  of  opinion  entertained  regard- 
ing the  transmission  of  tuberculosis  to  human  beings  through  the  process 
of  inhalation,  and  waiving  any  further  ronsidoi-ntion  of  thp  rohitive 
dangers  from  the  inspiration  of  dry  dust  m  insist  ilidiilcts,  the  fact 
remains  that  tubercle  bacilli  contained  in  h\iin:m  wimtuni  consiitute  a 
vitally  important  source  of  contagion.  Thi.s  introduces  a  i^liase  of  the 
subject  pertaining  to  invasion  through  the  alimentary  canal  which  it  is 
desired  to  emphasize,  i.  e.,  that  the  theory  of  transmission  of  the  disease 
through  this  channel  does  not  imply  the  presence  of  the  bovine  bacillus 
as  the  sole  or  principal  agent  of  infection.  Quite  to  the  contrary,  it  may 
be  asserted  that  in  a  large  majority  of  cases  gastro-intestinal  infection 
is  produced  by  the  entrance  of  bacilli  derived  from  tuberculous  sputum. 
While  the  tubercle  bacillus  of  bovine  origin  is,  beyond  question,  an 
important  factor  in  the  causation  of  tuberculosis  among  infants,  this 
bacillus  does  not  represent  the  only  element  of  danger,  even  among  chil- 
dren. It  produces  a  comparatively  infrequent  and  non-virulent  infec- 
tion in  adults.  It  is  desired  to  avoid  any  possible  impression  that 
the  digestive  tract  offers  a  pathway  chiefly  to  the  bovine  microorganism. 
Virulent  tubercle  Ijacilli  of  human  origin,  whether  emanating  from  dry 
dust  or  moist  droplets,  will  ever  remain  the  principal  source  of  infection. 
There  should  be,  therefore,  no  relaxation  of  previous  efforts  to  deal  in  a 
summary  manner  with  the  sputum  from  the  diseased  individuals. 

It  is  well  to  review  briefly  the  evidence  upon  which  is  founded  a 
belief  in  the  alimentary  canal  as  a  frequent  avenue  of  infection.  It 
may  be  added  parenthetically  that  a  provisional  assumption  regarding 
this  mode  of  bacillary  inva.sion  is  justified  by  virtue  of  the  fact  that 
other  hypotheses  have  failed  to  afford  a  perfectly  satisfactory  explana- 
tion of  the  frequent  transmission  of  the  disease.  To  present  in  detail 
the  numerous  experiments,  the  conclusions  derived  from  anatomic 
study,  and  the  various  theories  introduced  bearing  upon  different 
phases  of  the  problem  of  intestinal  infection  manifestly  is  imprac- 
ticable. It  is  sufficient  to  submit  an  outline  of  essential  facts  which 
have  been  subjected  to  definito  substantiation.  Several  considerations 
pertaining  to  this  su1>jim|  h.i\c  Keen  discussed  in  previous  chapters  in 
connection  with  iiiiii(ii1;iiit  fi^aiuios  of  infection.  It  has  been  pointed 
out  that  primary  IcsioiLS  of  tlie  intestine  are  not  nearly  so  rare  in 
children  as  has  been  asserted.  The  supposed  infrequency  of  this  condi- 
tion constituted  a  vital  argument  of  Koch  against  the  transmissibility 


52  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

of  tuberculosis  to  children  by  means  of  the  bovine  bacillus.  In  like 
manner  the  unusual  occurrence  of  primary  intestinal  tuberculosis  was 
regarded  as  de  facto  evidence  of  the  rarity  of  baciUary  invasion  through 
the  cUgestive  tract.  It  is  now  known,  however,  that  tubercle  bacilli 
pass  readily  through  the  intact  intestinal  mucous  membrane.  Atten- 
tion has  been  called  to  the  reported  observations  of  many  clinicians 
and  pathologists,  who  found  at  autopsy  upon  tuberculous  children 
primary  lesions  of  the  intestine  in  from  17  per  cent,  to  137  per  cent, 
of  the  cases.  Allusion  has  been  made  to  the  finchngs  of  numerous 
observers  who  noted  the  enormous  frequency  of  tuberculous  infection 
in  the  mesenteric  glands  of  children  dying  of  tuberculosis.  Wood- 
head  reported  this  condition  in  100  cases  out  of  127.  Moreover,  it  has 
been  emphasized  that  the  lymphatic  glands,  despite  entire  absence  of 
macroscopic  change,  have  been  found  in  many  instances  infective  to 
lower  animals.  The  valuable  experiments  of  Calmette  and  Guerin  in 
demonstrating  the  penetration  of  bacilli  through  the  intestinal  wall 
without  visible  lesion  have  been  described.  At  the  end  of  about  thirty 
to  forty-five  days  following  the  introduction  of  tuberculous  material 
through  the  esophageal  tube  the  mediastinal  glands  were  shown  to  be 
infscted.  The  mesenteric  glands,  which  were  the  first  structures 
involved,  often  exhibited  no  macroscopic  evidence  of  disease,  although 
the  tubercle  deposit  sometimes  took  place  after  a  single  infected  meal. 
The  inoculation  of  animals  with  these  glands,  as  well  as  with  appar- 
ently normal  mesenteric  glands,  produced  typical  tuberculous  lesions. 
After  a  continued  introduction  of  tuberculous  material  with  the  food  of 
animals,  bacilli  were  found  in  the  thoracic  duct  and  pulmonary  artery. 
In  the  chyle  vessels  the  bacilli  were  engulfed  by  the  leukocytes  and 
conveyed  to  regional  lymph-nodes  and  to  the  terminal  capillaries  in 
various  organs,  finally  to  become  arrested  and  produce  vascular  lesions. 
Engel  and  Schlossman  have  performed  similar  experiments  with  like 
results.  After  administering  tubercle  bacilli  in  milk  to  young  guinea- 
pigs  they  found,  in  the  course  of  a  few  hours,  these  microorganisms  in 
the  lungs.  There  is  permitted  a  strong  a.ssumption  that  the  mesenteric 
glands  present  no  barrier  to  the  advance  of  the  bacilli  after  the  manner 
of  the  defensive  action  of  other  lymphatic  glandular  structures.  On 
account  of  the  unobstructed  passage  through  these  glands  of  fat-droplets 
and  other  elements  during  digestion,  it  has  been  suggested  that  their 
function  is  somewhat  different  from  that  of  the  bronchial  lymph-nodes. 
It  appears  from  experimental  evidence  that  tubercle  bacilli  mixed  with 
the  fat  penetrate  the  intestinal  wall,  pass  through  the  mesenteric  glands, 
and  appear  in  the  thoracic  duct  with  almost  as  little  difficulty  as  do 
peptones  after  being  subjected  to  processes  of  digestion. 

It  has  been  shown  that  milk  from  tuberculous  cows  may  contain 
tubercle  bacilli  and  be  capable  of  producing  a  virulent  infection  in 
children.  The  observations  of  Fibiger  and  Jen.sen  have  been  quoted  as 
illustrative  of  the  added  dangers  of  milk  contamination  from  the  exist- 
ence of  local  lesions  upon  the  udder.  That  the  bovine  bacillus  is  respon- 
sible for  the  development  of  primary  intestinal  tuberculosis  in  children 
in  a  considerable  proportion  of  such  cases  has  been  shown  by  their  re- 
searches. Out  of  seven  cases  of  this  condition  observed  by  them,  five 
proved  to  be  of  bovine  origin,  as  shown  by  the  virulent  results  of  inoc- 
ulation into  calves  and  rabbits.  They  believe  that  infection  from  cow's 
milk  is  a  frequent  cause  of  primary  intestinal  lesions  in  children.     Ernst 


INFECTION   THROUGH   THE    DIGESTIVE   TRACT  53 

and  Hirschberger  have  called  attention  to  the  fact  that  despite  the 
absence  of  mammary  glandular  disease  the  milk  may  contain  tubercle 
bacilli.  The  evidence  as  to  the  entrance  of  bovine  bacilli  into  the 
alimentary  tract  of  children  is  beyond  dispute.  It  is  obvious,  how- 
ever, in  view  of  the  disproportion  between  the  large  number  of  infants 
ingesting  infected  cow's  milk  and  the  fewer  number  exhibiting  local 
lesions,  that  in  some  cases  this  bacillus  is  responsible  for  the  origin 
of  tuberculous  processes  so  common  in  childhood  in  other  parts  of 
the  body.  No  explanation  is  afforded  for  the  advance  of  the  ba- 
cillus to  the  glandular  structures,  liones,  joints,  and  meninges,  save 
upon  the  hypothesis  of  their  entrance  into  the  vascular  and  lymph- 
channels  from  the  intestinal  tract,  and  such  possibility  has  been  shown 
to  exist.  The  given  factors,  then,  in  the  problem  of  infantile  infection 
through  the  digestive  tract  are  as  follows:  an  alarming  prevalence  of 
the  disease,  with  local  manifestations  in  portions  of  the  body  accessible 
solely  through  the  lymphatic  and  vascular  channels,  unusual  exposure 
to  infection  through  the  digestive  canal  from  ingestion  of  bovine  and 
human  bacilli,  a  known  passage  of  the  microorganism  through  the 
delicate  structures  of  the  intestine,  and  the  subsequent  invasion  of  mesen- 
teric and  bronchial  glands,  and  the  demonstrable  presence  of  bacilli  in 
the  lymph-vessels. 

There  is  no  occasion  for  a  more  completely  sustained  argument 
regarding  the  alimentary  tract  as  an  important  route  of  invasion  iu 
children.  It  is  recognized,  of  course,  that  infection  takes  place  through 
other  channels,  but  an  analysis  of  clinical,  pathologic,  and  experimental 
data  affords  positive  evidence  as  to  this  port  of  entry.  The  early  local- 
ization of  tuberculous  lesions  in  bones  and  joints  among  children,  the 
frequency  of  glandular  infection,  the  rarity  of  pulmonary  or  laryngeal 
involvement,  are  supplemented  by  the  results  of  animal  experimentation. 

Whether  the  human  or  bovine  bacillus  is  the  principal  agent  of 
infection  in  these  cases  is  not  definitely  relevant  to  an  inquiry  devoted 
to  the  channels  of  invasion.  It  must  be  conceded  that  at  an  early 
period  of  life  especial  opportunities  are  afforded  for  the  entrance  of  both 
types  of  bacilli.  It  is  quite  impossible  to  attribute  all  cases  of  tuber- 
culosis to  a  latent  infection  with  the  bovine  bacillus  acquired  during 
infancy.  The  fallacy  of  this  reasoning  has  been  shown  by  the  prev- 
alence of  tuberculosis  in  countries  where  cow's  milk  is  seldom  em- 
ployed as  an  article  of  food  for  infants.  Behring's  theory  as  to  the 
transcendent  importance  of  the  infant's  milk  as  a  carrier  of  infec- 
tion, while  unwdrthv  <if  litcial  a(cc|itaiicc  in  its  entirety,  nevertheless  is 
formulated  upim  riTtain  fum  lament  a,l  tint  lis  and  to  a  great  extent, 
therefore,  is  entitled  t(i  a  iv(ciiti\c  ((insidcration.  The  anatomic  and 
physiologic  bases  for  his  (•(incliisKins  ((insist  of  the  absence,  in  little 
children,  of  such  a  digest  i\c  a|i|iaiatn-^  as  will  protect  the  system  from 
the  penetration  of  infoctnc  luiciiKniiainsms  into  the  body  fluids.  The 
experimental  evidence  which  he  submits  in  support  of  his  doctrine  of 
intestinal  infection  during  infancy,  as  the  chief  underlying  cause  of 
pulmonary  tuberculosis  in  later  years,  is  of  much  interest  and  value. 
He  showed  that  albuminous  mateiial  could  pass  unchanged  into  the 
circulation  through  the  inte.stinal  membrane  of  young  animals  without 
undergoing  digestion  and  conversion  into  peptones.  The  sera  of  diph- 
theria and  tetanus  antitoxins  containing  genuine  albumin,  after  intro- 
duction into  the  stomach  of  the  newly  born,  were  demonstrated  un- 


54  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

changed  in  the  blood.  Adult  guinea-pigis  to  whom  anthrax  bacilli 
free  from  spores  were  administeretl  with  the  food  were  unaffected  by  the 
bacilli,  which  were  evacuated  from  the  bowels.  Behring's  demonstra- 
tion relative  to  the  greater  ease  of  passage  of  microorganisms  through 
the  intestinal  wall  of  infants  than  in  adults  is  of  much  interest  in  connec- 
tion with  the  vastly  increased  prevalence  of  tuberculosis  in  early  life. 
It  does  not  follow,  however,  that  infected  milk  constitutes  the  sole 
means  of  conveyance  of  tubercle  bacilli  to  the  chgestive  tract  of 
infants.  The  practice  of  crawling  upon  the  floor  and  the  instinctive 
habit  of  placing  unclean  hands  and  a  wide  variety  of  soiled  articles 
in  the  mouth  undoubtecUy  result  in  the  introduction  of  sufficient 
bacilli  of  human  origin  to  induce  infection.  This  is  particularly  true 
in  families  harboring  careless  consumptives.  Tubercle  bacilli  have 
been  found  to  contaminate  the  hands  of  pulmonary  invalids  who  are 
accustomed  to  caress  their  children,  although  scrupulously  careful 
as  regards  kissing.  Mouth-breathing  and  the  con.sequent  lodgment 
of  the  bacilli  in  the  pharynx  afford  opportunity  for  their,  final  pass- 
age into  the  digestive  tract  in  the  act  of  swallowing.  Tubercle 
bacilli  have  been  found  in  large  numbers  in  the  dirt  retained  under  the 
nails  of  children.  In  addition  to  these  obvious  sources  of  infection 
an  important  method  of  bacillary  invasion  is  the  contamination,  by 
human  bacilli,  of  vegetable  and  animal  food  in  the  course  of  its  prepara- 
tion or  immediately  preliminary  to  its  consumption.  Infection  conve}^- 
ance  may  take  place  by  means  of  the  uncleanly  hands  of  a  careless  cook, 
while  in  the  act  of  coughing  there  also  is  permitted  a  wide  dissemi- 
nation over  the  food  of  finely  divided  though  invisible  particles  of 
sputum.  Exclusive  of  these  opportunities  for  infection,  the  food  is  often 
contaminated  after  it  has  been  placed  upon  the  table,  especially  in  places 
frequented  by  pulmonary  invalids,  the  agitation  of  handkerchiefs  and 
the  sweeping  of  skirts  upon  the  floor  resulting  in  a  temporary  sus- 
pension of  bacilli  in  the  atmosphere.  A  potent  cause  for  food  infection 
is  found  in  the  presence  of  the  domestic  fly.  The  bacilli  are  distributed 
not  only  by  the  feet  of  the  insect,  but  bj'  the  droppings  as  well.  The 
infective  material  is  taken  into  the  alimentary  tract  of  the  fly,  where  the 
bacilli  have  been  shown  to  multiply,  and  are  deposited  freely  upon  the 
food  in  the  form  of  specks.  According  to  Lord,  as  many  as  .5000  bacilli 
have  been  found  in  a  sinde  fly-speck.  He  computes  that  there  may  be 
depo.sited  within  a  period  of  three  days,  from  thirty  infected  flies,  nearly 
10,000,000  tubercle  bacilli.  The  chief  danger  from  this  source  results 
not  from  air  contamination,  but  rather  from  the  infection  of  food.  It 
thus  appears  that  even  among  adults  the  opportunities  for  an  initial 
invasion  through  the  digestive  tract  are  by  no  means  inconsiderable. 
In  the  light  of  all  the  evidence  that  has  recently  been  brought  to  bear 
upon  the  elucidation  of  the  physiologic  mechanism  involved  in  the 
various  methods  of  infection,  it  is  impossible  to  resist  the  logic  of  demon- 
strable facts,  and  deny  the  role  of  the  alimentary  tract  as  a  frequently 
traversed  pathway  of  bacillary  invasion. 

It  appears  almost  impossible  to  form  a  definite  estimate  concern- 
ing the  relative  frequency  of  inhalation  and  deglutition  tuberculosis. 
Although  the,  available  data  are  insufficient  to  warrant  even  approxi- 
mate conclusions  as  to  the  usual  route  followed  i>y  tubercle  bacilli 
in  their  entrance  into  the  body,  it  may  be  assumed  that  admission  is 
permitted  through  the  respiratory  tract  less  often  than  has  been  sup- 


DISTRIBUTION    OF   THE    BACILLI  55 

posed,  and  that  ingress  by  means  of  the  digestive  canal  is  correspond- 
ingly more  frequent.  The  acceptance  of  the  respiratory  and  alimentary 
tracts  as  the  two  principal  methods  of  bacillary  invasion  necessarily 
forces  the  conclusion  that  the  selection  of  either  route  is  determined  by 
the  special  opportunities  for  infection  in  different  instances.  According 
to  the  varied  conditions  of  exposure,  the  infection  may  take  place  in  some 
cases  with  far  greater  ease  by  means  of  one  method  than  the  other. 
Thus  children,  for  reasons  pertaining  to  their  food  and  habits,  may  be 
regarded  as  offering  unusual  facilities  for  the  entrance  of  bacilli  through 
the  digestive  canal,  while  adults,  who,  by  reason  of  peculiar  environment, 
are  compelled  to  live  in  an  atmosphere  contaminated  by  tubercle  Ijacilli, 
are  greatly  exposed  to  inhalation  tuberculosis.  In  either  event  the 
important  practical  consideration  must  relate  not  so  much  to  the  manner 
of  entrance  into  the  body  as  to  the  prevention  of  the  distribution  of  bacilli 
from  the  human  and  animal  organism. 


CHAPTER   VII 
DISTRBUTION  OF  THE  BACILLI 

The  living  human  and  animal  organism  is  not  only  the  natural 
abiding-place  of  the  tubercle  bacillus,  wherein  are  offered  favorable 
conchtions  for  multiplication,  but  is  also  the  all-important  agent  of 
distribution. 

The  principal  means  of  bovine  dissemination  is  from  the  ingestion 
of  infected  milk.  The  eating  of  animal  flesh  is  of  less  importance,  as 
in  most  cities  the  carcasses  are  subjected  to  rigid  inspection  before  the 
flesh  is  offered  foi'  public  consumption,  and  the  meat  almost  always 
is  thoroughly  cooked.  Tubercle  bacilli  may  sometimes  be  present  in 
the  milk  of  tuberculous  cows,  although  there  is  no  evidence  of  mammary 
infection,  but  the  danger  of  such  contamination  is,  of  course,  greater 
in  the  presence  of  udder  lesions.  Ravenel  has  demonstrated  the  possi- 
ble distribution  of  bovine  tubercle  bacilli  by  cows  in  the  act  of  cough- 
ing. The  sputum  was  collected  upon  a  piece  of  soft  pine  wood  placed 
in  the  bottom  of  a  nose-bag.  The  dissemination  of  bacilli  in  this  manner 
is  of  practical  significance  as  regards  the  dangers  of  infection  to 
those  brought  into  constant  association  with  cattle  and  to  animals 
confined  within  the  same  inclosure.  The  chief  means  of  exit  of  the 
bacillus  from  the  human  body  is  through  the  medium  of  the  expectora- 
tion. Irrespective  of  the  relative  frequency  of  infection  through  in- 
gestion into  the  alimentary  tract,  or  acquired  thi'ough  the  inhalation 
of  dried  siuituni  dust  and  of  moist  parlidc^  cxi idled  in  coughing, 
the  fact  rctii:iiiis  that  the  expectoration  r.ui-t  iiuir-  the  vehicle  for  an 
almost  uhi(i\iit(ius  dissemination  of  the  iincKMirgaiiism.  Bacilli  may 
also  be  eliminated  from  the  body  with  the  urine,  feces,  or  infected  pus 
through  a  discharging  sinus.  In  a  surprisingly  large  proportion  of  cases 
the  urine  of  consumptives  is  known  to  contain  tubercle  bacilli  even 
without  clinical  or  pathologic  evidences  of  genito-urinary  tuberculosis. 
Their  presence  in  the  feces  to  any  considerable  extent  is  conditional 


56  ETIOLOGY    AND    PATHOLOGIC    AXATOMY 

upon  the  existence  of  local  lesions  in  the  gastro-intestinal  tract.  The 
actual  distribution  of  bacilli  through  these  excretions  is  greatly 
reduced  b_v  the  comparatively  small  number  of  microorganisms  thus 
discharged,  by  the  sanitary  cUsposal  of  the  excrement,  and  by  the 
destructive  effect  of  putrefactive  change.  Sinus  discharges  containing 
bacilli  are  usually  received  upon  suitable  dressing  and  destroyed  without 
opportunity  for  bacillary  chstribution  other  than  obtains  from  contami- 
nation of  hands  or  clothing.  The  hands  of  careful  consumptives  have 
been  found  in  numerous  instances  to  be  the  repository  of  tubercle  bacilli. 
This  is  undoubtedly  true  to  a  great  extent  among  the  immediate  attend- 
ants of  pulmonary  invalids,  especiall}-  those  accustomeil  to  hantUe  tlie 
expectoration,  soiled  handkerchiefs,  and  articles  of  clothing.  The  linen 
and  blankets  particularly  are  in  danger  of  contamination,  and  laun- 
dresses, for  this  reason,  are  subject  to  more  or  less  exposure.  A  luxur- 
iant beard  adorning  the  face  of  a  consumptive,  especially  an  overhanging 
growth  upon  the  upper  lip,  represents  an  effective  means  of  bacillary  dis- 
tribution. 

Comment  has  been  made  upon  the  introduction  of  the  bacillus  into 
the  mouths  of  children  and  the  ea.se  with  which  food  maj'  be  infected  by 
means  of  soiled  hands  and  careless  coughing,  and  upon  the  role  of  the 
house-fly  as  a  cUstributing  agent.  Experiments  to  determine  the  exist- 
ence of  tubercle  bacilli  in  places  frequented  by  careless  consumptives  must 
be  accepted  as  conclusive  proof  of  their  emanation  from  dried  sputum 
dust.  In  open  places  exposed  to  sunlight  their  vitality  is  of  short  dur- 
ation, and  their  presence,  therefore,  of  slight  significance.  Only  in 
densely  populated  communities  are  streets,  pavements,  and  open  public 
resorts  likely  to  become  contaminated  to  a  serious  extent,  and  then  chiefly 
in  dark  alleys  and  courts,  where  frequent  sprinkling  or  washing  of  streets 
is  not  permitted.  The  continued  grinding  and  pulverization  incident 
to  passing  vehicles,  the  exposure  to  sunlight,  the  moisture  afforded  by 
nature,  the  frequent  sprinkling,  flushing,  and  sweeping  of  streets,  all 
conspire  to  render  the  actual  danger  from  outdoor  chstribution  of  bacilli 
in  large  centers  of  population  more  fancied  than  real.  Experiments 
have  shown  the  dust  to  contain  tubercle  bacilli  only  in  places  where 
consumptives  congregate  antl  indulge  in  gross  neglect  of  sanitarj'  precau- 
tions. The  dust  from  sidewalks  and  street-crossings  is  found  infective 
to  lower  animals,  particularly  in  resorts  where  municipal  regulations 
pertaining  to  expectoration  are  not  enforced.  In  view  of  the  present 
administrative  activity  regarding  street  cleanliness  it  is  probable  that 
the  practical  danger  of  the  dress-skirt  as  a  carrier  of  infection  from  the 
sidewalk  to  the  home  is  much  exaggerated.  There  can  be  no  possible 
doubt,  however,  as  to  the  enormity  of  the  exposure  within  dwelling-houses 
inhabited  by  ignorant  or  vicious  consumptives.  Aside  from  the  con- 
tamination of  clothing,  beckUng,  handkerchiefs,  beard,  hands,  and  food, 
the  bacilli  may  be  deposited  upon  the  wails  or  collected  upon  carpets  or 
draperies.  Being  heavier  than  the  air.  they  gravitate  to  the  floor  and 
settle  upon  carpets  or  rugs  and  in  numerous  dark  corners  or  recesses. 
When  not  exposed  to  direct  sunlight,  but  confined  in  close  rooms  without 
frequent  air  renewal,  their  vitality  is  continued  for  almost  indefinite 
periods.  When  subjected  to  continuous  agitation  by  drafts,  rustling 
of  skirts,  sweeping  and  dusting  of  rooms,  they  are  given  unusual  oppor- 
tunities to  acquire  entrance  into  the  human  bod}'.  The  ignorance  of 
many  housekeepers  as  to  the  proper  method  of  room-cleaning  is  respon- 


PREVALENCE  OF  TUBERCULOSIS  57 

sible  to  some  extent  for  the  general  dissemination  of  bacilli.  The  moist 
process  of  dusting  and  sweeping,  the  cleaning  of  rugs  in  the  open  air  or 
by  modern  methods,  diminishes  materially  the  dangers  arising  from 
house  infection.  The  investigations  of  Cornet,  Flick,  and  Hance  point 
not  necessarily  to  the  contamination  of  all  dwellings  inhabited  by  con- 
sumptives, but  merely  to  the  sources  of  danger  resulting  from  the 
presence  of  those  who  are  careless  or  ignorant.  It  may  be  assumed  that 
the  intelligent  and  conscientious  pulmonary  invalid  is  no  menace  to  the 
family  or  immediate  associates.  The  infectiousness  of  dust  from 
hospital  wards,  street-cars,  and  public  indoor  places  occupied  by  con- 
sumptives is  usually  demonstrable  only  when  negligence  of  ordinarj^ 
precautions  has  been  permitted.  Positive  results  from  inoculation 
were  obtained  in  one-fifth  of  Flick's  experiments,  but  in  no  case  where 
proper  attention  had  been  given  to  the  reception  of  sputum.  The 
investigations  of  Hance  along  similar  lines  resulted  in  negative  results 
in  dust  from  sixteen  out  of  seventeen  Adirondack  cottages,  the  exception 
being  due  to  a  careless  consumptive  who  had  indulged  in  expectoration 
upon  the  walls.  Gardiner  inoculated  the  dust  taken  from  different 
rooms  in  the  largest  hotel  in  Colorado  Springs,  which  had  been  occupied 
by  consumptives  for  many  years,  and  obtained  negative  results  in  each 
instance. 


CHAPTER  VIII 

PREVALENCE  OF  TUBERCULOSIS 

Consumption  is  universally  regarded  as  the  mo.st  dreaded  scourge 
of  the  human  race.  One-seventh  of  all  deaths  in  civilized  countries 
are  reported  to  result  from  this  disease,  and.  in  addition,  an  enormous 
proportion  of  individuals  harbor  unconsciously  latent  foci  of  infection. 
The  every-day  experience  of  pathologists  in  the  recognition  of  healed 
and  unsuspected  lesions  is  sufficient  to  demonstrate  the  wide  prevalence 
of  non-active  infections  and  the  inherent  powers  of  individual  resistance. 
Statistical  observations  concerning  the  frequency  of  tuberculous  lesions 
found  during  pastmortem  inquiry  have  varied  considerably,  according 
to  the  thoroughness  with  which  all  parts  of  the  body  have  been  explored. 
During  recent  years  these  researches  have  been  conducted  in  a  more 
systematic  manner  than  formerly,  and  reported  instances  of  latent 
infection  are  far  more  numerous.  Naegeli's  statistics  upon  this  subject, 
obtained  from  the  critical  study  of  500"autopsies  at  Professor  Ribbert's 
institute  in  Zurich,  are  particulaily  startling.  After  carefully  inspecting 
every  organ  of  the  body,  including  the  lymphatic  glands,  and  examining 
a  large  number  of  microscopic  sections,  he  reports  the  finding  of  tuber- 
culous lesions  in  97  per  cent,  of  all  the  cases  up  to  the  fifteenth  year,  96  per 
cent,  to  the  eighteenth  year,  and  nearly  100  per  cent,  up  to  the  fortieth 
year.  These  results  apparently  accord  with  the  popular  German  belief 
that  every  one  possesses  a  slight  focus  of  tuberculous  infection,  and 
tend  to  corroborate  the  old  English  idea  that  consumption  was  the  cause 
of  death  of  nearly  all  hard  zealots  in  the  field  of  letters,  law,  love,  medi- 
cine, and  religion.     The  discrepancy  between  the  vast  number  of  human 


58  ETIOLOGY    AXD    PATHOLOGIC    ANATOMY 

beings  harboring  localized  lesions  and  those  actually  succumbing  to  the 
disease  affords  a  striking  commentary,  as  previously  intimated,  upon 
the  effectiveness  of  self-immunization.  In  this  connection  it  is  only 
necessary  to  consider  the  many  individuals  who  perish  annually  from 
consumption  and  those  whose  capacity  as  wage-earners  is  restricted  by 
the  disease.  The  number  thus  afflicted  is  truly  appalling,  and  in  nearly 
all  countries  exceed.s  in  economic  loss  and  human  suffering  all  other 
combined  agencies  which  contribute  to  the  pathos  of  fate.  When  one 
considers  the  value  of  the  working  power  of  labor,  which  constitutes 
one  of  the  chief  commodities  of  the  State,  it  is  not  difficult  to  comprehend 
the  tremendous  depreciation  of  economic  I'esources  entailed  by  the 
ravages  of  such  a  pestilential  disease.  Even  without  regard  to  the 
magnitude  and  depth  of  human  suffering,  the  deprivations  and  blighted 
prospects  incident  to  prolonged  illness,  the  dismemberment  of  families, 
and  the  agony  of  heart  and  mind,  the  fact  remains  that  the  prevalence 
of  consumption  upon  the  basis  of  State  husbandry  constitutes  a  national, 
racial,  and  social  problem  comparable  to  which  none  other  is  worthy  of 
consideration.  The  statistics  concerning  the  frequency  of  tuberculosis 
are  too  familiar  to  justify  detailed  recapitulation,  but  a  few  illustrative 
statements  taken  from  recent  literature  are  of  much  interest. 

It  has  been  estimated  that  in  the  neighborhood  of  1,500,000  people 
are  annually  incapacitated  from  work  in  the  United  States  on  account 
of  this  affliction.  One  hundred  and  fifty  thousand  is  a  low  estimate  of 
the  number  whose  lives  are  terminated  bj'  tuberculosis  during  each 
year  in  this  country.  The  average  age  at  the  time  of  death  is  com- 
puted to  be  thirty-five  years,  enforcing  an  annual  preventable  loss 
to  the  nation  of  many  years  of  future  industrial  activity  approxi- 
mating half  of  man's  average  existence.  If  the  value  to  the  State 
of  each  healthy  inhabitant  during  the  entire  period  of  usefulness  is 
estimated  at  $1000,  the  economic  loss  in  one  year  from  deaths  so 
premature  must  approach  .$.500  for  each  individual  thus  removed, 
making  an  annual  drain  of  $75,000,000  upon  the  United  States  from 
this  source  alone.  This  is  entirely  exclusive  of  the  additional  ex- 
pense necessitated  for  the  maintenance  of  charity  organizations  and 
institutions  and  the  demands  imposed  by  the  disease  upon  private 
benevolence.  These  figures  form  a  very  conservative  estimate  of  the 
potential  loss  each  year  to  the  United  States  from  a  cause  admitted  to 
be  within  the  limits  of  prevention,  and  capable  of  producing  unutterable 
misery.  The  computations  of  many  students  of  political  economy  and 
observers  of  medical  conditions  far  exceed  those  given  above  in  an  esti- 
mate of  the  financial  loss  to  this  countrv  as  a  result  of  consumption.  By 
some  the  amount  is  stated  to  vary  from  $200,000,000  to  $400,000,000 
annually.  In  these  computations  are  included  the  deprivation  of 
working  capacity  as  bread-winners  for  the  family,  the  expenditure  of 
the  savings  of  non-producers,  the  provision  for  children  dying  under 
twenty  years,  the  care  of  those  helplessly  ill,  and  the  maintenance  of 
institutions.  A  commission  recently  appointed  in  Mas.sachusetts  to 
investigate  the  prevalence  of  pulmonary  tuberculosis  in  that  State 
reports  upon  the  score  of  replies  received  from  physicians  and  the  number 
of  consumptives  within  the  various  public  institutions,  that  nearly 
8000  individuals  at  present  are  suffering  from  the  disease.  As  675 
physicians  failed  to  give  information  in  response  to  circular  letters, 
the  number  of  consumptives  now  residing  in  Massachusetts  may  be 


INFLUENCE    OF    RACE  59 

assumed  to  be  somewhat  larger.  About  one-third  were  in  the  inci- 
pient stage,  and  an  equal  number  in  advanced  and  in  far-advanced 
phthisis.  Biggs  states  that  in  New  York  city,  during  the  year  1902, 
16,000  cases  of  consumption  were  reported  to  the  Health  Department; 
in  1903,  17,000;  and  in  1904,  19,000  cases.  In  1905  nearly  32,000  ca.ses 
were  reported,  of  which  over  11,000  were  duplicates,  and  in  1906,  30,826, 
of  which  10,741  were  duplicates.  He  has  presented  much  valuable 
data  concerning  tuberculosis  in  the  city  of  New  York  from  1881  to  the 
present  time.  From  his  statistical  tables  it  appears  that  at  least  10,000 
people  die  annually  from  consumption  in  that  city.  It  is  probable  that 
if  nearly  20,000  cases  of  e.xisting  tuberculosis  are  reported  to  the  health 
authorities,  nearly  half  as  many  more  are  afflicted  without  the  cognizance 
of  the  department.  About  as  many  people  die  of  phthisis  in  Illinois 
annually  as  in  the  city  of  New  York.  The  same  is  practically  true  of 
the  State  of  Ohio.  In  Englantl  one-fourth  of  all  deaths  occurring  during 
the  period  of  useful  activity  are  reported  to  result  from  consumption, 
while  in  Prussia  this  disease  produces  one-third  of  all  deaths  in  infants. 
In  Austria  the  tuberculin  test  has  recently  been  employed  upon  healthy 
soldiers,  with  a  positive  result  in  60  per  cent,  of  those  who  were  presum- 
ably well,  suggesting  again  the  remarkable  distribution  of  latent  infec- 
tion. An  important  practical  question  presents  itself,  as  to  whether  or 
not  (•onsunii)ti()ii  is  actually  diminishing  in  prevalence  as  the  result  of 
intelligent  systcinatic  effort  toward  its  restriction.  Satisfying  results  are 
reported  from  New  York  city,  where  the  reduction  in  the  doath-rate 
from  tuberculo.sis  is  nearly  one-half  in  the  pa^■t  iwcut)  \iais.  The 
percentage  of  deaths  per  1000  population  is  reportid  \>y  l',i;^u,s  to  have 
been  4.45  per  cent,  in  1884,  and  to  have  diminished  gratlually  to  2.49  per 
cent,  in  1903.  In  London  it  was  3.12  per  cent,  in  1884  and  2.34  per  cent, 
in  1901;  in  Berlin,  3.6  per  cent,  in  1884  and  2.39  per  cent,  in  1902;  in 
Vienna,  7.2  per  cent,  in  1884  and  4.76  per  cent,  in  1900;  in  Philadelphia, 
3.32  per  cent,  in  1861;  in  1884,  3.1  per  cent.;  in  1903,  2.25  per  cent. 
In  Paris,  however,  the  death-rate  is  not  shown  to  have  diminished,  the 
percentage  being  5.19  per  cent,  in  1SS4  anfl  5.46  per  cent,  in  1900.  In 
Berlin,  while  the  total  tuberculosis  mmtality  has  been  reduced,  the 
infantile  death-rate  from  tubciculcjsis  lias  been  increased  somewhat 
during  the  past  thirty  years.  Statistical  observation  with  reference  to 
the  diminished  prevalence  of  tuberculosis  in  Colorado  will  be  given  in 
connection  with  geographic  differences  of  distribution. 


CHAPTER   IX 

INFLUENCE  OF  RACE 

No  phthisio-therapeutist  of  ample  experience  can  deny  the  existence 
of  essential  differences  among  various  races  in  the  degree  of  resistance 
to  pulmonary  tuberculosis.  An  effort  has  been  made  by  some  statis- 
ticians to  attribute  the  radical  divergence  in  the  mortality  rate  among 
nations  to  changes  of  environment  rather  than  to  variations  of  inherent 
susceptibility.     There  can  be  no  doubt  that  in  some  instances  the  sur- 


t»U  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

rounclings  and  mode  of  life  are  responsible  in  large  measure  for  the 
present  high  death-rate  from  consumption.  This  obtains  particularly 
with  reference  to  the  negro  population  of  the  United  States.  It  is 
impossible,  however,  to  reconcile  the  chfferences  in  this  country 
between  the  Irish.  Swedes,  Germans,  English,  Americans,  and  Polish 
Jews  upon  the  basis  of  environment.  It  is  not  true  that  among  these 
people  there  exists  a  remarkable  dissimilarity  in  immechate  surroundings 
and  mode  of  life  or  in  the  nature  of  climatic  influences  unless  it  be  that 
the  Poles,  who,  of  all  nations,  exhibit  the  very  greatest  resistance  to  con- 
sumption, suffer  from  the  most  unfavorable  conchtions.  In  America, 
the  home  of  all  races,  it  is  questionable  if  the  negro  undergoes  greater 
privation  or  is  subjected  to  more  unsanitary  conditions  than  the  ignorant 
and  poverty  striken  Jewish  emigrants  from  Poland,  yet  these  two  races 
exhibit  opposite  extremes  in  the  mortality  rate  from  tuberculosis.  While 
the  influence  of  environment  and  methods  of  living  are  reacUly  conceded 
to  produce  salient  chfferences  in  powers  of  incUvidual  resistance,  it  is 
none  the  less  clear  that  a  distinct  effect  is  exerted  by  virtue  of  racial 
predisposition. 

The  negro  race  in  the  United  States  is  exceedingly  susceptible 
to  tuberculosis,  and  environment  must  be  admitted  to  play  an  im- 
portant part.  Consumption  is  reported  almost  to  have  been  unknown 
upon  the  West  coast  of  Africa,  as  well  as  in  the  interior,  until  the  natives 
were  brought  in  contact  with  imported  cases.  Though  seldom  before 
intUgenous,  tuberculosis  once  established  among  the  colored  people  has 
been  found  to  pursue  a  rapid  and  relentless  course,  presumably  on 
account  of  the  non-acquirement  of  partial  immunity  as  a  result  of  trans- 
mission through  earlier  generations.  The  original  transplantation  of  the 
negro  to  the  southern  part  of  the  United  States  was  not  attended  imme- 
diately by  such  disastrous  consequences  in  the  way  of  tuberculous  infec- 
tion as  might  be  expected  from  the  radically  changed  surroundings  and 
conditions.  From  a  previous  existence  of  barbarism,  the  slave,  though 
brought  for  the  first  time  into  close  association  with  the  disease,  neverthe- 
less was  permitted  a  life  in  the  open  air.  While  his  lot  was  necessarily 
one  of  hard  and  useful  toil,  he  was  provided  with  commocUous  quarters 
and  an  abundance  of  food  in  a  climate  not  sufficiently  rigorous  to  produce 
suffering  from  exposure,  nor  to  involve  inadequate  ventilation  of  apart- 
ments. Prior  to  the  Civil  \^'ar,  consumption,  while  scarcely  an  unknown 
disease  among  the  negroes,  was  still  comparatively  rare.  Upon  the 
acquirement  of  personal  freedom  there  resulted  inevitably  such 
change  of  conditions  as  to  produce  a  remarkable  increase  in  the  suscep- 
tibility of  the  race  to  the  ravages  of  tuberculosis.  This  did  not  take 
place  solely  through  the  eagerness  of  the  negro  to  move  North  and  the 
endeavor  to  secure  an  adaptation  to  a  more  severe  climate,  for  the  disease 
flourished  almost  to  the  same  extent  among  those  remaining  in  the  South 
and  those  living  in  Xe%v  England.  Of  all  cities  in  the  country,  however, 
Boston,  with  a  colored  population  of  12.000,  is  reported  to  have  the 
highest  death-rate  of  tuberculosis  among  these  people. 

The  rational  explanation  of  an  increased  prevalence  of  the  disease 
among  the  negroes  is  referable  to  the  very  fact  of  their  independence. 
Formerly  they  were  compelled  to  work  in  the  open  fields,  and  in  most 
instances  were  comfortably  housed  and  fed.  In  later  years  they  have 
flocked  to  the  large  cities,  congregated  in  great  numbers  in  unhealthful 
abodes,  and  have  sought  employment,  if  at  all,  under  conditions  less 


INFLUENCE    OF    RACE  61 

favorable  than  in  the  days  of  slavery.  It  is  not  strange  that,  with  the 
sudden  enforced  assumption  of  the  responsibilities  of  self-maintenance, 
for  which  the  negro  in  no  way  was  prepared  by  mental  equipment  or 
previous  experience,  he  should  develop  to  a  certain  extent  hal^its  of 
idleness,  intemperance,  unsanitary  living,  and  excessive  sexual  indul- 
gence, with  resulting  venereal  taint.  Syphilis,  alcohol,  improper  food, 
and  insufficient  ventilation  assuredly  are  potent  agencies  in  the  develop- 
ment of  a  predisposition  to  tuberculosis  in  any  race.  Supplementary 
to  these  detrimental  influences  an  important  causative  factor  is  the 
peculiar  nature  of  the  occupation  of  the  negro  people  as  a  class.  Aside 
from  their  availability  for  domestic  service,  their  illiteracy  and  shift- 
lessness  limit  the  remaining  avenues  of  work  to  drudgery  in  coal  mines, 
hard  labor  as  operatives  in  factories  and  mills,  menial  employment  as 
porters  in  railway  cars  or  steamships,  waiters,  cooks,  janitors,  and 
laundresses.  All  work  of  this  nature  entails  a  degree  of  confinement 
with  unusual  opportunities  for  infection.  For  the  above  reasons  it  is 
no  wonder  that  the  susceptibility  of  the  negro  to  consumption  is 
greater  than  that  of  all  other  races.  Professor  Jones,  of  the  Hamp- 
ton Normal  and  Agricultural  Institution,  states  that  the  mortality 
rate  for  the  colored  people  is  from  two  to  seven  times  that  shown 
by  any  other  race  except  the  Irish,  who  exhibit  two-thirds  the 
mortality  rate  of  the  negro.  The  colored  children,  particularly  under 
fifteen  years  of  age,  are  prone  to  succumb  to  tuberculous  infection,  the 
mortality  being  seven  times  that  of  white  chUdren  regardless  of  nation- 
ality. An  important  consideration  pertaining  to  the  problem  of  tuber- 
culosis among  the  colored  people  is  the  exceedingly  large  number  of 
negroes  in  the  United  States.  The  proportion  to  the  total  population 
is  greater  than  that  of  any  other  alien  class  of  Americans.  They  com- 
prise 8,000,000  people,  and  constitute  11  per  cent,  of  our  total  number 
of  inhabitants.  The  high  mortality  rate  from  consumption  among  a 
class  who  form  so  large  a  porportion  of  our  people  invests  the  problem 
with  far  greater  significance  than  relates  to  the  prevalence  of  the  disease 
among  other  races  in  our  midst,  who  not  only  are  decidedly  less  suscep- 
tible, but  include  a  much  smaller  number  of  inhabitants.  It  is  worthy 
of  more  than  passing  attention  that  consumption  creates  its  greatest 
havoc  among  the  very  people  who  constitute  the  largest  part  of  our 
alien  population  and  who,  as  servants,  are  brought  into  far  more  intimate 
contact  with  the  home  life  than  the  Irish,  Germans,  Scandinavians, 
French,  Russians,  or  Poles. 

The  alarming  development  of  tuberculcsis  among  the  American 
Indians  pre.sents  some  points  of  .similarity  to  the  spread  of  the  disease 
among  the  negroes,  and  with  equal  propriety  may  be  attributed  in  part 
to  radical  changes  of  immediate  environment.  To  be  sure,  the  Indians 
have  not  been  forcibly  imported  to  a  new  country,  but  they  have  been 
rudely  driven  from  their  own  possessions  by  the  encroachments  of  the 
white  people,  who,  in  conferring  the  questionable  blessings  of  civiliza- 
tion, have  been  directly  responsilile  for  the  decimation  of  the  race  by 
disease.  From  the  available  data  bearing  upon  the  subject  it  is  fair  to 
assume  that  consumption  among  the  Indians  was  of  extremely  rare 
occurrence  prior  to  their  contact  with  European  races.  Since  that  time 
the  disease  has  gradually  increased  until  at  present  it  has  assumed  the 
proportions  of  a  veritable  scourge.  The  ravages  of  tuberculosis  are 
more  pronounced  among  the  Indians  of  the  older  reservations  than  of 


62  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

the  newer  agencies  in  the  Northwest,  suggesting  an  increasing  prevalence 
in  proportion  to  the  greater  restrictions  placed  upon  their  nomaclic 
existence.  The  frecjuency  of  consumption  among  the  Indians  of  all 
tribes  has  been  noted  by  the  physicians  appointed  to  care  for  the  various 
agencies.  Some  have  reported  47  per  cent,  of  all  deaths  to  result  from 
this  cause.  Others  have  placed  the  percentage  at  66,  and  still  others 
at  75  and  even  95.  The  development  of  tuberculosis  among  the  Indians 
has  been  frequently  cited  as  a  conspicuous  instance  of  the  dangers  of 
infection  pure  and  simple.  While  it  is,  of  course,  true  that  the  disease 
could  not  have  been  transmitted  save  from  contact  with  the  tubercle 
bacillus,  other  equally  important  factors  have  been  introduced,  strongly 
enforcing  a  predisposition  to  infection.  In  fact,  the  spread  of  pulmonary 
tuberculosis  among  the  tribes  occupying  reservations  noted  for  favorable 
climatic  influences  is  in  itself  prima  facie  evidence  as  to  the  existence  of  a 
gros.sly  unhealthful  environment  as  well  as  to  the  practice  of  pernicious 
habits  calculated  to  lessen  vital  resistance.  It  is  known  that  the  IncUans 
have  ever  been  inclined  to  keep  singularly  aloof  from  the  white  people, 
whom  they  regard  with  suspicion.  The  cUsease  has  spread  among  a  class 
of  beings  who  are  kept  more  or  less  secluded  in  their  reservations  and  are 
accustomed  to  an  outdoor  existence,  in  contradistinction  to  the  negroes, 
who  have  sought  indoor  employment  in  large  centers  of  population  and 
have  been  expo.sed  to  numerous  opportunities  for  infection.  A  study, 
however,  of  the  present  conditions  ol itaining  in  most  reservations  is  pecu- 
liarly enlightening  in  explanation  of  the  development  and  mortality  of  the 
disease.  Dr.  J.  R.  Walker,  Agency  Physician  at  Pine  Ridge,  South  Da- 
kota, has  recently  reported  interesting  data  with  reference  to  tuberculosis 
among  the  Oglala  Sioux  IncUans.  Dr.  I.  E.  Brewer,  of  Fort  Huachuca, 
Arizona,  presents  a  review  of  the  development  of  tuberculosis  among 
the  IncUans  of  Arizona  and  New  Mexico,  embodying  reports  from  the 
Colorado  River  Agency  (Mojave  IncUans),  the  White  River  Agency 
(Apache),  the  Hopi  Reservation  (Hopi  and  Navajo),  the  Navajo  Reser- 
vation (Navajo),  the  Fort  McDowell  (Apache),  Pima  Agency  (Maricopas, 
Pimas,  and  Papagoes),  the  Walapai  Reiservation  (Hovasupai  and 
Walapai),  the  Mescalero  Reservation  (Apaches),  the  Santa  F6  Agency 
(Puebloes),  and  the  Zuni  Reservation  (Puebloes).  While  unanimity 
of  opinion  is  found  to  exist  with  reference  to  the  wide  prevalence  of 
consumption  among  all  tribes,  the  reports  are  also  uniform  regarding 
the  presence  of  concUtions  strongly  predisposing  to  the  disease.  During 
his  primitive  life  the  Indian  was  habituated  to  an  almost  continuous 
out-of-door  existence.  Though  compelled  to  endure  great  hardship  and 
subjected  at  times  to  severe  physical  exertion,  undue  exposure,  insuffi- 
cient clothing,  accustomed  to  improperly  cooked  food,  and  with  extreme 
irregularity  as  to  the  time  of  eating,  he  nevertheless  was  comparatively 
free  from  tuberculosis  on  account  of  the  invigorating  influence  of  his 
open-air  life.  His  career  was  e.ssentially  nomadic  in  character,  consisting 
of  hunting  or  maraucUng  expeditions  and  internecine  warfare.  Though 
filthy  to  a  degree,  the  evil  effects  were  minimized  by  the  frequent  moving 
of  camps  and  the  construction  of  tepees  permitting  ample  ventilation  at 
the  top.  The  disposal  of  .slops  ancl  excrement,  while  un.sanitary  in  the 
extreme,  was  non-productive  of  practical  harm  on  account  of  the  short 
period  of  accumulation.  With  the  erection,  however,  of  permanent 
houses,  which  were  small,  low,  and  with  perfectly  tight  roofs,  all  oppor- 
tunity for  ventilation  was  prevented.     Every  facility  likewise  was  offered 


INFLUENCE    OF    RACE  63 

for  the  subjection  of  the  inmates  to  other  unhealthful  conditions,  includ- 
ing exposure  to  all  manner  of  infective  material.  From  a  life  in  the  open 
air  the  Inchans  were  wont  to  congregate  in  large  numbers  in  overheateil 
rooms,  with  no  ventilation  whatever  and  without  the  slightest  concep- 
tion of  other  principles  of  hygienic  living.  Upon  one  of  their  number 
becoming  the  victim  of  tuberculosis,  no  precautions  were  taken  to 
prevent  the  spread  of  the  infection.  Expectoration  was  promiscuous 
and  usually  indoors.  In  view  of  these  conchtions  it  is  no  wonder  that 
the  race  has  been  threatened  with  extinction,  but  there  is  no  suggestion 
of  an  inherent  predisposition  to  tuberculosis  as  the  sole  factor  in  the 
appalling  spread  of  the  disease.  In  contrast  with  the  negro,  the  Indian 
constitutes  but  1  per  cent,  of  our  total  population,  and  is  brought  but 
little  in  contact  with  the  white  people.  The  prevalence  of  consump- 
tion among  the  Indians  upon  the  western  and  southwestern  reservations 
strikingly  illustrates  the  truism  that  to  secure  immunity  from  tuberculo- 
sis it  is  not  altogether  ivhere  one  lives,  but  in  what  manner. 

The  Irish  people,  both  at  home  and  in  other  countries  where  they 
reside,  have  been  notoriously  susceptible  to  tuberculosis.  In  the  United 
States  the  mortality  rate  is  two-thirds  that  of  the  negro,  being  approxi- 
mately 4  to  1000  of  the  population.  This  is  much  in  excess  of  other 
nationalities  in  America,  the  Scandinavians  and  Bohemians  having  a 
death-rate  of  but  little  over  one-half  that  of  the  Irish.  According  to 
Jones's  mortality  chart,  the  Germans,  as  well  as  French,  Scotch,  and  Can- 
adians, have  a  death-rate  of  one-half  that  of  the  Irish  and  one-third  that 
of  the  negroes.  The  mortality  rate  of  the  Engli.sh,  Ru.ssians,  Italians, 
Hungarians,  and  Americans  from  tuberculosis  is  still  less.  The  rate  for 
the  Poles  is  least  of  all,  being  0.625  per  1000.  These  statistical  con- 
clusions are  closely  in  accord  with  Lillian  Brandt's  table  of  mortality 
of  races,  and  conform  to  my  own  clinical  observations  concerning 
the  degree  of  resistance  shown  by  different  nationalities  in  a  suitable 
climate.  A  large  number  of  patients  of  various  races  under  similar 
conditions  of  climate  and  management  were  found  to  display  remarkable 
differences  in  their  ability  to  withstand  the  disease.  Ten  years  ago 
I  cited  the  disproportionate  resistance  shown  by  the  Jews  in  compari- 
son with  the  Americans,  English,  Germans,  and  Scotch,  and  the  slighter 
recuperative  power  of  the  Irish  and  Swedes.  The  Irish  were  reported  to 
be  predisposed  to  a  special  degree,  the  tuberculous  process  being  active, 
as  a  rule,  and  attended  with  early  cavity  formation.  There  was  noted 
a  marked  tendency  to  septic  and  nervous  chsturbances,  and  the  patients 
were  found  somewhat  hard  to  control.  This  was  explained  in  part  by 
their  volatile  mercurial  disposition,  but  lessened  powers  of  resistance 
were  also  displayed  by  those  not  exhibiting  an  unstable  nervous  tem- 
perament and  conforming  implicitly  to  a  strict  disciplinary  regime. 

The  Swedes,  though  apparently  hardy  and  vigorous,  were  found, 
as  a  rule,  to  succumb  much  more  cjuickly  than  patients  of  our  own 
country.  They  were  excessively  apprehensive,  impressionable  to  a 
degree,  and  inclined  to  ea-sy  discouragement,  but  usually  obedient  to 
instructions.  The  same  was  true  to  a  great  extent  of  the  Bohemians, 
the  majority  of  these  people  arriving  in  Colorado  with  extensive  areas 
of  pulmonary  involvement,  somewhat  out  of  proportion  to  the  relatively 
short  period  of  illness.  It  has  been  my  general  experience  that  the 
Germans,  English,  Canadians,  and  even  the  Scotch  readily  adapted  them- 
selves to  an  appropriate  system  of  living,  excelling  in  this  respect  our 


64  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

more  restless  Americans.  There  has  seemed  to  obtain  in  most  instances 
a  lighter  burden  of  business  responsibilities  and  a  more  phlegmatic  or 
philosophic  disposition,  with  less  of  general  restlessness  or  irritability. 
The  American  has  often  announced  upon  arrival  that  he  had  come  to 
Colorado  for  a  few  proscribed  months,  that  his  recovery  must  take  place 
within  that  period,  as  no  further  extension  of  time  could  be  diverted 
from  his  business. 

The  clinical  exhibition  of  resistance  on  the  part  of  the  Jews  has  been 
something  remarkable.  In  spite  of  extensive  and  long-standing  pulmo- 
nary disease,  the  nutrition  and  strength  have  been  maintained  to  a  sur- 
prising degree.  I  have  been  impressed  repeatedly  by  the  disproportion 
between  the  physical  signs  and  the  general  condition.  Severe  mixed 
infection,  from  my  observation,  is  much  less  frequent  than  among  all 
other  races.  On  the  other  hand,  the  process  of  arrest  has  been,  as  a  rule, 
rather  slow  and  disappointing.  It  would  appear  that  the  Jew  posses.ses 
a  certain  immunity  to  the  toxemia  of  tuberculosis  which,  despite  exten- 
sive destructive  change,  enables  him  to  withstand  the  disease  for  pro- 
longed periods,  but  that  the  powers  of  resistance  are  often  insufficient  to 
produce  healing  of  the  tuberculous  lesions.  The  tenacity  with  which 
these  people  retain  their  hold  upon  life  in  the  presence  of  advanced 
pulmonary  phthisis  is  sometimes  cited  as  illustrative  of  the  immunizing 
influence  resulting  from  the  transmission  of  the  disease  during  the  course 
of  many  generations.  Be  this  as  it  may,  the  fact  remains  that  there  does 
exist  an  inherent  resistance  to  the  ravages  of  tuberculosis  among  the.se 
people.  The  peculiar  character  of  the  clinical  manifestations  among  the 
Jews  may  not  be  justly  attributed  to  environment  alone,  for  in  large  cities 
the  ignorant  are  crowded  into  densely  populated  districts  and  subjected  to 
the  direst  poverty,  the  hardest  of  indoor  work,  the  inhalation  of  vitiated 
atmosphere,  and  the  habitation  of  apartments  often  noisome  with  filth. 
Attempts  to  explain  the  diminished  prevalence  of  tuberculosis  among 
such  people  upon  the  score  of  their  obeyance  of  the  Mosaic  law  pertaining 
to  meat  and  drink  is  unscientific  and  chimerical.  Even  were  all  the 
meat  rejected  by  the  Rabbis  assumed  to  come  from  tuberculous  animals, 
there  is  no  assurance  that  the  flesh  is  thus  infected,  and  even  so,  the 
process  of  cooking  is  known  to  destroy  all  germ  life.  This  is  not  to  be 
construed  to  the  disparagement  of  municipal  efforts  toward  rigid  inspec- 
tion of  meats  offered  for  public  consumption.  Immunity  to  tuber- 
culosis among  the  Jews  has  been  improperly  attributed  to  their  avoid- 
ance of  pork,  which  is  alleged  to  be  tainted  with  tuberculous  infection 
on  account  of  the  known  existence  of  the  disease  among  swine.  It  is 
probable  that  the  abstinence  from  alcohol  and  the  rarity  of  syphilis 
among  the  Jews  are  important  factors  in  sustaining  powers  of  resi-stance 
unavoidably  weakened  by  overcrowding,  insufficient  food,  and  unhealth- 
ful  surroundings.  While  the  prevalence  of  consumption  among  these 
people,  as  with  other  races,  is  undoubtedly  influenced  to  some  extent 
by  the  conditions  under  which  they  live,  it  seems  well  established  that 
the  Jews  are  less  responsive  to  unfavorable  conditions  that  other  nation- 
alities. A  study  of  the  development  of  tuberculosis  among  the  Jewish 
poor  of  New  York  city  has  been  conducted  by  Fishberg,  and  of  Chicago, 
by  Sachs.  The  latter  believes  that  the  disease  is  on  the  increase  among 
the  Hebrews  in  Chicago,  and  that  their  immunity  is  overestimated,  but 
ascribes  an  increasing  prevalence  to  abject  poverty  and  unsanitary 
conditions. 


INFLUENCE    OF   GEOGRAPHIC    POSITION 


CHAPTER   X 

INFLUENCE  OF  GEOGRAPHIC  POSITION 

For  maziy  years  the  effect  of  climate  upon  the  development  of  indi- 
genous tuberculosis  has  been  the  subject  of  much  professional  specula- 
tion. At  one  time  it  was  believed  that  a  certain  degree  of  immunity 
was  established  in  warm  regions,  and  patients  suffering  from  tuber- 
culosis were  sent  to  localities  free  from  low  tenii)eratures,  regardless  of 
other  considerations.  Later  an  equable  climate  was  regarded  as  the 
chief  desideratum,  irrespective  of  moisture  or  sunshine.  Dryness  as 
opposed  to  humicUty  for  a  time  was  accepted  as  of  prime  importance. 
The  character  of  the  soil  was  regarded  as  a  factor  of  some  moment  in 
the  causation  of  tuberculosis,  and  marshy  or  clay  ground,  which  re- 
tained surface  moisture,  was  thought  to  be  less  favorable  than  a  sandy 
or  rocky  formation.  Sunshine  and  purity  of  the  air,  wherever  found, 
have  been  espoused  by  some  as  the  chief  elements  in  promoting 
individual  resistance.  Elevated  regions  were  thought  to  grant  an 
immunizing  power  to  consumptives,  and  much  statistical  data  have 
been  introduced  in  apparent  siilistantiation  of  this  claim.  Modei'ate 
altitudes  were  also  found  in  cnnibine  the  maximum  amnunt  of  .-sun- 
shine and  dryness,  though  lacking  equability.  In  addition  to  tlie 
diathermancy  exhiljited  in  such  localities,  varying  degiccs  oT  wind 
movement  resulted  in  the  dissemination  of  dust.  Clinmte  /k  /  m  is 
believed  by  a  few  to  possess  no  advantages  whatever,  the  Of->eiitial  con- 
sideration being  thought  to  be  mere  change  of  surroundings,  all  consider- 
ations of  sunshine,  dryness,  altitude,  etc.,  being  regarded  as  negligible 
factors.  Upon  the  basis  of  this  reasoning  the  consumptive  in  Colorado, 
as  Fisk  aptly  remarks,  may  be  expected  to  achieve  signal  improvement 
by  a  winter's  sojourn  in  Boston  in  order  to  secure  the  benefits  of  real 
change.  The  efficacy,  even  of  a  new  environment,  is  repudiated  by  others 
who  in  recent  years  have  memorialized  the  advantages  of  door-steps, 
back  yards,  fire-escapes,  and  house-tops  in  crowded  cities.  While  the 
benefits  accruing  from  these  primitive  facilities  for  securing  rest  in 
the  open  air  are  beyond  dispute  and  worthy  of  elaboration  for  those 
unable  to  avail  themselves  of  greater  change,  it  is  .significant  that  the 
alleged  advantages  to  be  derived  from  home  life  are  rarely  taken  advan- 
tage of  by  physicians  when  personally  stricken  with  consumption.  It  is 
apparent  from  the  contradictory  opinions  entertained  by  medical  men, 
that  no  single  climate  grants  immunity  to  tuberculosis,  and,  in  fact,  such 
is  actually  the  case.  Consumption  is  known  to  occur  in  all  regions, 
whether  dry  or  moist,  high  or  low,  warm  or  cold.  The  vital  considera- 
tion in  the  development  of  the  di.sease  among  people  inhabiting  a 
certain  locality  relates  not  to  the  climatic  conditions  alone,  hut  also  to 
the  crowding  of  the  population  and  the  character  ol  the  Livneral  occu- 
pation. The  absence  of  tuberculosis  in  new  countries  lia\ing  sparsely 
settled  communities  and  with  the  early  settlers  living  in  the  open  air 
offers  in  itself  no  evidence  of  climatic  influence  favoring  resistance  to 
infection.  For  this  reason  reported  observations  as  to  the  infre- 
quency  of  consumption  in  certain  regions  where  these  or  similar  condi- 
tions exist   are  practically  valueless.      Rational   conclusions  may  be 


bb  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

derived  only  from  reference  to  the  climatic  attributes  obtaining  in  the 
populous  cities  of  selected  districts  where  other  conditions  offer  a  suitable 
basis  for  comparison  as  to  the  tuberculosis  mortality  rate.  Judged 
by  this  token,  the  evidence  is  conclusive  regarcUng  the  relative  degree 
of  immunity  conferred  through  the  influence  of  altitude  combined  with 
dryness  and  sunshine.  The  infrequency  of  tuberculosis  in  parts  of 
Algiers,  the  Russian  Steppes,  Iceland,  and  Hebrides,  all  at  low  altitudes, 
is  explained  by  the  smaD  number  of  inhabitants  and  the  ab.sence  of 
crowding  or  industrial  pursuits.  In  like  manner  the  slight  prevalence 
of  the  disease  in  the  elevated  regions  of  Africa  and  India  may  be  ascribed 
to  the  same  cause.  Observations,  however,  concerning  the  frequency 
of  consumption  in  large  centers  of  population  at  low  elevations  in  the 
interior,  and  in  such  cities  at  moderate  altitudes  as  Denver,  City  of 
Mexico,  Santa  Fe,  Colorado  Springs,  Albuquerque,  and  Las  Vegas, 
are  properly  eligible  for  comparison.  Gardiner  has  written  in  no 
uncertain  tone  of  the  remarkably  low  mortality  rate  from  non-imported 
consumption  in  Colorado  Springs,  at  an  altitude  of  6000  feet.  The 
development  of  indigenous  pulmonary  tuberculosis  in  Denver,  a  city 
of  tall  buildings,  large  mercantile  establishments,  department  stores, 
and  factories,  with  200,000  inhabitants,  many  of  whom  represent  cases 
of  imported  consumption,  has  been  the  subject  of  some  tlifference  of 
belief  among  medical  observers.  Some  years  ago  the  opinion  was  prom- 
ulgated by  highly  efficient  health  officers  that  non-imported  tuber- 
culosis was  increasing  at  a  prodigious  rate.  This  view  was  indorsed 
to  some  extent  by  a  committee  appointed  by  the  State  Medical  Society 
in  1901  to  investigate  and  report  concerning  the  actual  status  of  such 
development.  At  the  invitation  of  the  El  Paso  County  Medical  Society 
I  conducted  a  systematic  investigation  concerning  the  matter,  and 
reported  the  results  of  my  endeavor  in  an  address  delivered  before  the 
Society  at  Colorado  Springs  in  the  latter  part  of  1901 .  This  was  repeated 
by  request  before  the  Denver  and  Arapahoe  County  Medical  Society  in 
January  of  the  following  year.  The  questions  involved  are  of  such 
importance  that  in  discussing  the  data  concerning  the  development  of 
indigenous  tuberculosis  in  Colorado  I  find  it  ad\isable  to  utilize  a  portion 
of  the  material  contained  in  my  previous  study  of  the  subject . 


CHAPTER    XI 


TO  WHAT  EXTENT  IS  CONSUMPTION  INDIGENOUS  IN 
COLORADO? 

It  was  formerly  asserted  by  some  that  pulmonary  tuberculosis  con- 
tracted in  Colorado  constituted  a  very  important  factor  in  mortality 
statistics.  An  indigenous  disease  was  thought  to  be  increasing  at  such 
a  rate  an;^!  assuming  such  proportions  as  to  demand  for  its  restriction 
drastic  measui'es  in  the  way  of  legislative  and  municipal  supervision. 
Although  heartily  in  sympathy  with  all  rational  measures  of  con- 
trol, I  have  been  unable  to  accept  the  evidence  presented  to  sub- 
stantiate the  alleged  increasing  prevalence  of  such  cases.     It  may  be 


TO    WHAT    EXTENT   IS    CONSUMPTION    INDIGENOUS    IN    COLORADO  ?     67 

admitted  that  consumption  has  been  contracted  in  Colorado,  as  in  other 
centers  of  popidation,  and  that  to  some  extent  it  may  be  expected  to 
originate  here  in  the  future.  It  is  only  with  reference  to  the  desiree  and 
practical  significance  of  its  development  that  an  unprejudiicd  iiii|iiiry 
is  solicited.  Although  consumption  is  communicable,  it  iu'\citli('li  >■<  is 
acquired  chiefly  by  those  rendered  susceptible  through  en\ir(jiinient, 
occupation,  previous  conditions,  and  other  unfavorable  influences.  The 
infection  is  known  to  be  often  slow  and  incremental  in  character,  pro- 
longed exposure  and  in  some  instances  repeated  infection  being  neces- 
sary to  overcome  individual  resistance  sufficiently  to  produce  clinical 
manifestations  of  the  disease.  It  is  to  be  expected,  therefore,  that 
consumption  should  occa.sionally  develop  in  Colorado  as  a  natural  result 
of  the  massing  of  population,  embracing  all  classes,  from  affluence  to 
poverty,  and  including  all  degrees  of  predisposition.  The  disease  should 
not  be  ascribed  solely  to  an  intimate  association  with  imported  pulmo- 
nary invalids,  although  there  must  inevitably  develop  frequent  chsregard 
of  precautionary  measures.  A  considerable  number  of  the  people  in 
Colorado  pursue  a  peculiarly  unfavorable  occupation,  to  which  may  be 
attributed  to  some  extent  the  occasional  development  of  pulmonary 
phthisis.  Miners  are  subjected  for  prolonged  periods  to  entire  absence  of 
sunshine  and  to  the  inhalation  of  an  atmosphere  deficient  in  oxygen  and 
vitiated  by  dampness,  dust,  and  smoke.  Exposure  to  such  conditions 
day  after  day  cannot  fail  to  exert  a  deleterious  influence  throughout  the 
respiratory  tract  and  produce  a  soil  notoriously  favorable  for  infection. 
A  large  portion  of  the  younger  population  in  Colorado  are  born  of  tuber- 
culous parents,  and  in  early  life,  when  especially  predisposed,  subjected 
to  continued  undue  exposure.  As  a  legitimate  result  of  these  factors 
the  origin  of  segregated  cases  of  consumption  is  conceded,  but  this 
constitutes  no  argument  detrimental  to  the  value  of  altitude,  sunshine, 
and  dryness.  The  fact  that  the  disease  has  not  attained  greater  propor- 
tions is  a  remarkable  tribute  to  the  restraining  influence  of  a  beneficent 
climate.  Present  interest  attaches  to  a  consideration  as  to  whether  or 
not  consumption  developed  in  Colorado  is  increasing  to  any  material 
extent  from  year  to  year.  Upon  the  answer  to  this  question  depends 
in  great  measure  the  proper  attitude  of  the  local  profession  with  reference 
to  a  problem  extremely  difficult  of  solution  and  capable  of  affonling 
honest  differences  of  opinion.  It  is  at  once  cxiilcnt  that  the  sitiunion 
demands  a  calm,  judicial  inquiry,  the  evidence  ])|csciiIim1  Id  cdij^isl  <>{  a 
cold  analysis  of  statistical  facts  and  not  tlouiiKitic  Dpinidus  or  picron- 
ceived  ideas. 

During  the  past  fifteen  years  public  attention  has  been  repeatedly 
drawn  to  an  alleged  rapid  increase  in  the  number  of  deaths  from  con- 
sumption contracted  in  Colorado. 

A  review  of  the  matei'ial  offered  as  evidence  to  establish  the  large 
proportion  of  cases  originating  in  this  State  to  those  contracted  elsewhere 
indicates  that  the  chief  source  of  information  is  found  in  the  former 
records  of  the  Denver  Health  Department.  In  the  annual  report  for 
1896  it  was  stated  tliat  the  numberof  deaths  duringthe  previous  year  from 
tuberculosis  devclopod  in  Colorado  "is  a  little  more  than  one-sixth  of 
the  total  tuberculous  i  Icat  li-rate."  It  was  noted  al.so  that  the  percentage 
of  deaths  from  tulicrculosis  contracted  in  this  State  had  been  progress- 
ively increasing.  In  1893  the  proportion  was  stated  to  be  11.25  per  cent. ; 
in  1894,  1.3.7  per  cent. ;  in  1895, 15  per  cent. ;  in  1896, 18.4  per  cent.    Later 


tm  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

reports  from  the  Health  Department  showed  the  proportion  in  1897  to 
be  18  per  cent.,  and  in  1898.  19.7  per  cent.  The  source  of  information 
upon  which  these  statistics  were  compiled  was  the  returns  upon  the 
death-certificates. 

The  percentage  of  deaths  is  by  no  means  a  fair  criterion  of  the  pro- 
portion in  Denver  of  cases  said  to  have  developed  in  Colorado  to  those 
contracted  elsewhere.  The  pulmonary  invalid  from  a  ili.stance,  with 
a  hopeless  prognosis,  is  usually  advised  to  return  home.  Compara- 
tively few  such  patients,  fortunately,  are  permitted  to  die  in  Denver, 
removed  from  family  and  friends.  The  proportion,  then,  of  one  to  six 
does  not  properly  apply,  as  might  be  inferred,  to  the  existing  cases  of 
tuberculosis  in  Colorado. 

It  is  easy  to  demonstrate  the  fallacy  of  an  alleged  rapid  increase  in  the 
percentage  of  deaths  from  tuberculosis  contracted  here.  It  is  apparent 
that  a  given  ratio  may  be  radically  transformed  by  a  change  in  either  of 
its  terms.  In  other  words,  the  percentage  of  deaths  from  tuberculosis 
developed  in  Colorado  may  be  increased  from  year  to  year  by  reason  of 
an  increase  in  the  number  of  such  deaths,  f)rovided  the  total  tuberculous 
death-rate  remains  unchanged.  Upon  the  other  hand,  if  the  entire 
death-rate  from  tuberculosis  is  diminished,  the  proportion  of  indig- 
enous cases  may  be  increased,  although  the  actual  number  be  less  than 
in  previous  j-ears. 

While  the  figures  of  the  Health  Department  previously  cited  show 
the  percentage  to  have  increased  very  rapidly,  the  actual  number  of  cases 
originating  in  Colorado  was  but  slightlj-  larger  for  the  four  years,  while 
the  total  number  of  deaths  from  tuberculosis  was  considerably  less; 
this,  of  course,  effecting  an  increase  in  the  proportion,  but  possessing 
no  further  significance.  Thus  in  1893  the  total  number  of  deaths  from 
tuberculosis  was  reported  as  435,  of  which  49  were  specified  as  contracted 
in  Colorado,  establishing  a  percentage  of  11.2.5.  The  next  year  the 
total  number  was  377,  a  diminution  of  58,  while  the  number  contracted 
in  Colorado  w'as  51,  an  increase  of  but  two  cases  for  the  entire  year.  It 
is  obvious  at  once  that  the  increase  is  entirely  insignificant,  yet  the 
proportion  is  published  as  being  13.7  per  cent.,  a  gain  of  2.5  per  cent,  in 
the  deaths  originating  in  Colorado  for  the  year. 

An  analysis  of  the  statistics  for  1895  and  1896  gives  practically  the 
same  results.  The  number  of  deaths  in  1896  is  but  two  more  than  for 
1895,  and  but  17  more  than  for  1893,  in  spite  of  an  increase  in  that  time 
of  26,000  in  the  population.  }'et  the  percentage  is  much  increased  in  1896 
on  account  of  a  diminution  of  60  in  the  total  tuberculous  death-rate. 

It  is  of  much  interest  to  note  that  the  statistics  for  1899,  furnished 
by  the  Health  Commissioner,  were  decidedly  at  variance  with  those 
previou.sly  reported,  and  serve  to  some  extent  as  an  official  refutation  of 
the  asserted  rapid  increase  of  pulmonary  tuberculosis  in  Colorado. 
Despite  a  material  increase  in  the  population  of  Denver  since  1893,  the 
number  of  cases  specified  as  having  developed  in  1899  was  but  four  more 
than  in  1893,  and  the  percentage  of  such  cases  to  the  total  deaths  from 
tuberculosis  was  but  9.9,  about  one-half  that  reported  for  the  three 
previous  years,  and  less  than  any  proportion  which  has  been  determined 
since  1893.  The  compilation  of  these  statistics  was  based  upon  the  same 
official  sources  of  information  as  in  the  previous  years. 

In  the  summer  of  1901  the  mortality  statistics  of  consumption  were 
reviewed  upon  the  basis  of  the  returns  collected  by  tne  State  Board  of 


TO    WHAT    EXTENT    IS    CONSUMPTION    INDIGENOUS    IN    COLORADO?    69 

Health  rather  than  the  Denver  Healtli  Department,  during  the  sixteen 
months  included  between  Junuarv,  I'.KIO,  and  May,  1901.  An  investi- 
gation conducted  by  different  otficiiils  through  the  channels  of  another 
department  and  perhaps  in  accordance  with  other  methods  might 
be  expected  to  disclose  a  cUfference  in  final  results  entailing  a  pos- 
sible mochfication  of  previous  conclusions.  It  is  interesting  to  learn, 
therefore,  that  the  proportion  of  deaths  from  consumption  developed  in 
the  State  to  the  total  tuberculous  death-rate  for  the  sixteen  months 
during  which  the  statistics  were  collaborated  was  stated  to  be  13.32  per 
cent.  This  chanced  to  be  the  same  proportion  as  was  published  by  the 
Denver  Health  Department  for  1894,  and  failed  to  indicate  on  the  face 
of  the  returns  any  increase  whatever  in  such  deaths  during  a  period  of 
seven  years.  As  a  matter  of  fact,  the  proportion  was  about  one-third 
less  than  that  reported  for  1897  and  1898. 

Unfortunately,  from  1901  to  1904  the  Health  Commissioner  of  the 
city  of  Denver  preserved  no  record  pertaining  to  cases  of  pulmonary 
tuberculosis  contracted  in  Colorado.  After  diligent  search  it  has  been 
impossible  to  discover  any  data  upon  which  to  compile  statistics  of  this 
nature  during  his  tenure  of  office. 

According  to  the  official  annual  report  of  the  statement  of  deaths 
for  the  city  and  county  of  Denver  by  the  Health  Department  in  1905, 
there  were  39  cases  of  pulmonary  tuberculosis  stated  to  have  developed 
within  the  State,  as  compared  with  a  total  mortality  rate  from  tuliei-- 
culosis  of  661,  establishing  a  proportion  of  only  5.9  per  cent.,  wliich  is 
less  than  any  year  since  the  compilation  of  such  statistics  in  1893.  In 
1906,  however,  an  increase  was  noted  over  the  preceding  year,  there 
being  58  cases  reported  to  have  developed  within  the  State  as  compared 
with  a  total  death-rate  from  this  disease  of  634,  making  the  percentage 
9.1,  which  chances  to  be  smaller  than  in  1893,  or  any  succeeding  year  up 
to  1905. 

Another  aspect  of  the  subject  is  the  significance  of  an  annual  increase 
in  the  population,  which  was  not  formerly  considered  in  the  official 
computation  of  vital  statistics  in  the  State.  While  possiljilities  of  error 
necessarily  attend  any  effort  to  determine  the  rehitions  of  indigenous 
consumption,  perhaps  no  method  is  as  satisfactory  in  alTonlinti-  approx- 
imate conclusions  as  the  proportion  of  such  cuscs  to  I  lie  population. 
Accepting  the  figures  of  thr  ITcaltli  Department  relative  to  the  popula- 
tion of  Denver  and  the  niiiiilier  ot  deatiis  annually  from  primary  tuber- 
culosis since  1893  as  an  eiiiiiieiiil\  fair  hasis  for  analysis,  the  percentage 
of  such  deaths  per  1000  inhabitants  was  found  to  vary  but  little  from 
year  to  year,  the  proportion  being  less  in  1894  than  in  1893;  in  1896, 
slightly  less  than  in  1895,  and  in  1899,  three  per  10,000  people  as  com- 
pared with  three  and  a  fraction  in  1893.  Apropos  of  these  results, 
attention  is  directed  to  the  report  of  the  Committee  upon  Tuberculosis, 
which  stated  that  for  the  first  eleven  months  of  1900,  the  only  time 
during  which  statistics  were  compiled,  the  percentage  of  such  deaths 
to  the  present  population  was  three  persons  per  10,000  people.  This 
coincided  singularly  with  my  analysis  of  death  reports  for  previous 
years,  being  practically  identical  with  results  obtained  for  1899  and  1893, 
being  even  less  than  in  1894,  and  presenting  but  trifling  fluctuation  in 
succeeding  years.  From  this  comparison  it  was  seen  that  the  Com- 
mittee's report  failed  to  demonstrate  the  slightest  increase  of  indigenous 
consumption  from  the  time  the  agitation  received  its  inspiration. 


70  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

As  previously  stated,  there  are  no  available  statistics  pertaining  to 
this  subject  during  1901,  1902,  1903,  and  1904. 

The  proportion  of  deaths  from  indigenous  tuberculosis  in  1905, 
according  to  the  official  report  of  the  Denver  Health  Department,  is  less 
than  two" per  10,000  people;  in  1906,  a  little  over  two  for  10,000  people, 
in  both  years  being  less  than  any  percentage  previously  obtained. 

Still  another  phase  of  the  subject  is  the  relation  of  infantile  tuber- 
culosis mortality  to  the  total  deaths  from  consumption  contracted  in 
Colorado.  An  analysis  of  data  obtained  from  the  Denver  Health 
Department  showed  that,  of  all  persons  reported  to  have  died  of  tuber- 
culosis originating  within  the  State  during  a  period  of  seven  years,  up  to 
1900.  nearly  one-fourth  were  children  under  four  and  five  years  of  age, 
of  whom  85  per  cent,  died  of  tuberculous  meningitis.  During  the  follow- 
ing year,  out  of  a  series  of  76  cases,  concerning  which  special  detailed 
information  was  obtained,  27,  or  over  one-third  of  the  entire  number,  were 
untler  five  years  of  age.  Manifestly,  in  view  of  the  special  predisposition, 
such  infantile  cases,  without  qualifjdng  explanation,  should  not  be  in- 
cluded as  instances  of  death  from  indigenous  pulmonary  tuberculosis. 

A  similar  consideration  deserving  mention  is  that  of  occupation. 
It  is  found,  by  reference  to  the  report  of  the  Tuberculosis  Committee, 
that  out  of  a  total  of  224  cases  49,  or  more  than  one-fifth,  occurred 
among  miners.  The  vast  importance  attaching  to  so  large  a  propor- 
tion among  this  class,  modifying  as  it  does  any  superficial  conclusions, 
is  appreciated  when  one  considers  that  the  tuberculous  element  is 
subordinate  to  other  pathologic  changes,  and  occurs  as  a  mere  final 
development.  It  is  suggested  that  these  patients  scarcely  ever  asso- 
ciate with  consumptives,  but  e.xhibit  a  constant  disregard  of  general 
hygienic  laws  which  involve  subsequent  tissue  changes  insuring  a  favor- 
able soil.  Obviously,  these  cases  should  not  be  instanced  as  examples 
of  the  dangers  of  every-day  infection. 

As  bearing  directly  upon  this  line  of  thought,  the  attention  of  the 
student  is  directed  to  the  location,  in  the  State,  of  reported  indigenous 
ca.ses.  El  Paso  County,  containing  a  greater  relative  proportion  of 
consumptives  than  any  other,  and,  therefore,  likely  to  yield  the 
largest  percentage,  presents  the  remarkably  small  nuniber  of  six  cases, 
or  about  ^V  of  the  whole.  Gilpin  County,  with  a  much  smaller  popu- 
lation, among  whom  consumptives  are  exceedingly  infrequent,  the 
people  being  comprised  largely  of  miners,  offers  a  percentage  nearly 
three  times  as  great. 

A  factor  of  no  inconsiderable  importance,  to  which  attention  was 
called  by  me  in  1897,  is  the  entire  absence  of  proof  that  cases  reported 
as  developing  in  Colorado  were  actually  contracted  here.  It  was  con- 
tended that  the  mere  fact  of  an  individual  exhibiting  physical  signs  of 
tuberculosis  less  than  one  year  after  arrival  is  no  evidence  of  its  having 
originated  in  Colorado. 

The  arbitrary  inclusion  of  such  cases  unavoidably  implies  a  non- 
acceptance  of  the  theory  of  a  latent  tuberculous  process,  and  is  op- 
po.sed  to  the  incontrovertible  testimony  adduced  in  recent  years  as 
to  the  extraordinary  frequency  of  unsuspected  tuberculous  infection. 
Many  Colorado  phy.sicians,  from  their  daily  experience,  can  testify 
concerning  individuals  apparently  sound,  with  clear  eye,  bronzed  cheek, 
and  well-rounded  proportions,  yet  victims  of  an  incipient,  if  not  active, 
infection.     Is  it  not  probable,  among  the  large  number  of  people  coming 


TO    WHAT    EXTENT   IS    CONSUMPTION    INDIGENOUS    IN    COLORADO?     71 

to  this  State  accompanying  invalid  relatives  and  friends,  with  indi- 
vidual resistance  subsequently  diminished  through  hardships  undergone 
and  privations  endured,  that  some  have  developed  an  active  process 
from  an  infection  previously  latent?  If  this  be  true,  it  may  be  asked, 
by  virtue  of  what  right  should  it  be  assumed  that  the  development  of  the 
disease  in  apparently  healthy  people  is  sufficient  ground  to  assert  its 
origin  in  Colorado,  without  recourse  to  investigation  and  without  at 
least  a  residence  in  the  State  of  one  or  more  years? 

I  am  unable  to  understand  how  a  reasonable  interpretation  of  official 
data  justifies  a  conclusion  as  to  an  alarming  increase  of  indigenous  cases. 
If  consumption  contracted  in  Colorado  is  actually  increasing  to  any 
extent  year  by  year,  it  remains  to  be  demonstrated  by  statistical  obser- 
vations not  as  yet  introduced. 

Let  it  be  understood  that  no  negative  testimony  is  presented  in 
rebuttal  of  the  positive  claims  of  those  with  whom  I  have  been  forced 
to  differ.  The  position  originally  assumed  was  taken  solely  from  the 
analysis  of  their  own  recorded  official  statistics,  the  authenticity  of  which 
has  never  been  disputed.  It  is  admitted  that  clinical  reports  from  con- 
servative and  painstaking  observers  furnish  testimony  from  time  to  time 
concerning  the  occasional  existence  of  indigenous  cases.  That  a  more 
interested  attention  is  being  devoted  to  the  investigation  and  report  of 
such  cases  is  certainly  a  source  of  congratulation  and  gives  promise  of 
perhaps  more  definite  future  knowledge.  From  information  thus  far 
received,  however,  it  would  appear  that  in  a  large  proportion  of  the  cases 
reported,  there  had  been  abundant  icason  for  the  development  of  the 
disease  by  virtue  of  a  marked  inliciiicd  taint,  the  presence  of  some 
recognized  predisposing  cause,  ucciiiiation,  or  special  exposure.  This 
is  illustrated  somewhat  by  ni}-  own  experience,  which  comprises  a 
list  of  35  cases  out  of  a  series  of  2070  cases  seen  in  private  practice 
during  a  period  of  sixteen  years.  In  9,  occupation  may  be  justly  con- 
sidered to  bear  an  important  relation  to  the  etiology,  3  being  old  miners, 
3  stone-cutters,  1  a  layer  of  carpets,  1  employed  in  a  steam  laundry,  ancl 
1  a  cigar-maker.  With  2  a  very  reasonal^le  doubt  may  be  entertained 
as  to  the  origin  of  the  disease  in  Colorado,  1  having  developed  it  six 
months  after  arrival  and  the  other  having  been  in  Sweden  upon  a  long 
visit  immediately  before  the  disease  manifested  itself  in  this  State.  With 
6  others  there  was  a  distinct  history  of  great  exposure  to  infection,  such 
as  would  endanger  health  in  any  climate.  Another  is  an  instance  of 
pulmonary  tuberculosis  occurring  in  a  child  whose  mother  died  of 
consumption  three  weeks  after  he  was  born.  The  remaining  cases  are 
offered  as  examples  of  tuberculosis  contracted  in  spite  of  a  favorable 
climate,  for  which  no  explanation  is  made.  One  of  these  developeil 
tuberculosis  complicating  a  long-standing  diabetes,  another  in  associ- 
ation with  chronic  interstitial  nephritis,  2  in  conjunction  with  pro- 
nounced habits  of  dissipation,  and  4  following  severe  influenza.  No 
mention  is  made  of  the  several  cases  of  tuberculous  meningitis  occurring 
during  the  first  one  or  two  years  of  life  in  infants  born  of  tuberculous 
parents,  as  these  do  not  appear  to  come  within  the  scope  of  this  inquiry. 

Although  deprecating  all  sensationalism  that  tends  to  inspire  alarm, 
there  is  advocated  no  abatement  of  the  hearty  support  to  be  accorded 
to  health  authorities,  nor  of  earnest  and  combined  efforts  along  the  lines 
of  preventive  medicine.  Measures  necessary  for  the  restriction  of  con- 
sumption should  be  enforced  in  Colorado,  as  in  other  States. 


72  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 


CHAPTER   XII 

GENERAL    CONDITIONS   INFLUENCING   INFECTION 
AFTER  EXPOSURE  TO  THE  TUBERCLE  BACILLUS 

An  inherited  predisposition  to  consumption  is  commonly  regarded 
as  a  feature  of  the  utmost  importance,  although  modern  opinion  con- 
cerning the  etiologic  significance  of  the  family  history  is  quite  divergent. 
A  mass  of  statistics  has  been  cited  by  various  observers  to  demonstrate 
and  also  to  refute  the  influence  of  heredity  in  the  development  of  the 
disease,  and  it  almost  appears  that  both  the  affirmative  and  the  nega- 
tive contention  may  be  substantiated  by  analytic  inquiry.  Statistics 
concerning  this  phase  of  pulmonary  tuberculosis  are  usually  collaborated 
with  reference  solely  to  tuberculosis  in  the  immecUate  antecedents, 
irrespective  of  such  other  features  as  the  time  of  its  development,  its 
duration,  the  degree  of  association  permitted  with  other  members  of 
the  family,  the  environment,  and  the  opportunities  for  infection.  These 
factors,  if  investigated  properly,  often  clothe  the  compiled  results  with 
far  greater  importance.  Without  elaborate  inquiry  along  collateral 
lines,  analytic  reports  concerning  an  inherited  predisposition  are  devoid 
of  special  practical  interest. 

The  vital  consideration  relates  not  to  the  fact  that  one  or  more 
members  of  the  family  died  of  consumption,  but  chiefly  to  the  time, 
conditions,  and  circumstances  under  which  the  disease  existed.  Chil- 
dren whose  parents  subsequently  became  tuberculous  belong  to  an 
entirely  different  category  from  those  whose  progenitors  were  con- 
sumptives at  the  time  of  conception.  The  opportunities  for  post- 
natal infection  /are  frequently  sufficient  to  prevent  an  assumption 
concerning  the  precise  influence  of  an  inherited  predisposition.  The 
tubercle  bacillus  is  present  to  a  particularly  dangerous  extent  in 
houses  inhabited  by  pulmonary  invalids,  and  at  no  age  is  greater 
opportunity  afforded  for  acquirement  of  the  infection  than  during 
infancy.  In  the  majority  of  cases  the  es.sential  element  in  the  prop- 
agation of  the  disease  among  children  is  not  the  inheritance  of  a 
tuberculous  taint  or  predisposition  from  infected  parents,  but  rather 
an  undue  vulnerability  of  tissues  peculiar  to  infants  and  an  excessive 
exposure  to  sources  of  acquired  infection.  These  conclusions  appear 
justified  by  the  results  of  clinical  experience  in  a  health  resort  extensively 
frequented  b}^  pulmonary  invalids.  In  several  instances  I  have  seen 
children  of  perfectly  health}-  parents  .succumb  to  tuberculous  infection, 
explainable  upon  inquiry  by  contact  with  a  pulmonary  invalid.  On 
the  other  hand,  children  of  tuberculous  parents  have  often  been  observed 
to  thrive  to  a  remarkable  degree  upon  enforcement  of  rigid  precautionary 
measures.  I  have  in  mind  a  child  of  two  and  a  half  years  both  of  whose 
parents  are  tuberculous.  The  infant  at  birth  weighed  less  than  four 
pounds,  was  a  typical  "blue  baby,"  and  lost  nearly  one  pound  during 
the  first  two  weeks  of  life.  The  evidences  of  physical  debility  were  pro- 
nounced, malnutrition  persisting  for  a  long  time.  Though  reared 
exclusively  upon  modified  milk,  the  infant  finally  attained  a  surprising 
degree  of  nutrition  and  vigor.  To  minimize  opportunities  for  postnatal 
infection  the  child  has  been  kept  under  the  successful  management  of  a 
nur.se  in  an  isolated  portion  of  the  house. 


CONDITIONS   INFLUENCING    INFECTION    AFTER    EXPOSURE  73 

There  is  to  be  expected,  of  course,  a  diminished  resistance  in  chil- 
dren born  of  parents  with  waning  strength  and  vigor  as  a  result  of 
pulmonary  tuberculosis,  carcinoma,  nephritis,  syphilis,  severe  nervous 
disturbances,  and  old  age.  This  impaired  vitality,  unless  incident 
to  infantile  syphilis,  bears  no  inherent  relation  to  the  specific  nature 
of  the  parental  constitutional  condition.  It  does  not  characterize 
tuberculosis  alone,  and  is  due  not  to  the  cause  of  the  parental  weak- 
ness, but  to  the  debility  itself.  The  offspring  displays  a  lessened  resist- 
ance to  disease  in  general,  with  no  greater  precUsposition  to  tuberculosis 
than  to  some  other  affection  only  in  so  far  as  its  wide  prevalence  furnishes 
greater  opportunities  for  acquired  infection.  It  has  been  shown  that 
children  with  lessened  powers  of  inherent  resistance  to  disease  never- 
theless may  thrive  by  virtue  of  especially  favorable  conditions. 

The  relation  of  environment  to  infection  is  of  considerable  interest. 

It  is  somewhat  doubtful  to  what  extent  an  increased  vulnerability 
of  the  tissues  to  tuberculous  infection  may  result  from  external  causes. 
It  is  quite  impossible  to  state  the  relative  importance  of  lowered  resist- 
ance and  direct  exposure  as  causative  factors  in  the  development  of 
the  disease.  It  has  been  the  tendency  in  recent  years  to  ascribe  the 
spread  of  tuberculosis  more  directly  to  the  distribution  of  the  bacillus, 
and  preventive  measures,  therefore,  have  been  directed  almost  exclu- 
sively toward  its  destruction.  Through  the  influence  of  societies  for 
the  prevention  of  tuberculosis  and  the  administrative  efforts  of 
municipal  and  State  health  authorities  the  attention  of  the  profession 
has  been  called  to  the  necessity  of  removing  all  possible  sources  of 
bacillary  infection.  Commendable  as  has  been  this  work  along  the 
lines  of  preventive  medicine,  it  is  apparent  that  there  exists  to  some 
extent  an  unconscious  inclination  to  overlook  the  etiologic  significance 
of  conditions  pertaining  to  the  every-day  life.  It  may  be  assumed  that 
the  factor  of  paramount  importance  in  the  production  of  tuberculosis 
is  the  presence  of  the  tubercle  bacillus,  and  that  efforts  toward  its 
removal  will  be  attended  with  a  gratifying  diminution  in  the  prevalence 
of  the  disease.  It  may  be  asserted,  however,  with  equal  positiveness, 
that  the  possibility  of  bacillary  invasion,  its  degree  and  result ,  arc  urcatly 
modified  by  the  receptivity  of  the  soil.  The  activity  of  ilw  tulictiii- 
lous  infection  is  extremely  variable  in  different  people  sul>ji(  nd  \u  pre- 
cisely the  same  conditions.  Among  several  members  of  a  family  siiriciing 
equal  degrees  of  exposure  the  development  of  the  disease  ina>-  Vie 
observed  in  but  a  single  instance,  or,  if  in  more  than  one.  with  tlie  \iru- 
lence  of  the  infection  strikiuiiiyiUssiniihir.  This  distin^nuisliiuu  .IHTerence 
in  incUvidual  receptivily  is  dhseiNcd  in  ]iris(ins,  i-elnrniaturies.  I  laii  ;icl'CS, 
and  even  among  the  attendants  (if  r(insiinip(i\'es  in  sanalmia.  I'm- a 
long  time  it  has  been  recognized  as  a  clinical  truism  that  races  and 
families  manifest  a  remarkable  difference  in  the  degree  of  susceptibility 
to  infection  and  in  the  power  of  sulisequent  resistance.  If  such  condi- 
tions are  found  beyond  question  to  exist  with  reference  to  faniilies  and 
nations,  it  is  reasonable  to  expect  corresponding  indivi(hial  \ariatiiins 
in  the  types  of  infection.  Important  controlling  factors  relate  to  the 
methods  of  living,  the  habits,  occupation,  and  social  conditions.  Exceed- 
ing importance  attaches  to  the  existence  of  hygienic  surroundings, 
adequate  ventilation,  sufficient  food,  proper  clothing,  the  absence  of 
excesses,  and  the  avoidance  of  oppressive  cares  and  burdensome 
vexations. 


74  ETIOLOGY    A\D    PATHOLOGIC    ANATOMY 

Consumption  has  been  found  to  afflict  the  poor  oftener  than  the  well- 
to-do,  the  ignorant  more  than  the  educated,  the  vicious  and  intemperate 
rather  than  the  refined  and  gentle,  and  those  who  are  mentally  depressed 
and  despondent  rather  than  the  cheerful  and  sunny  in  disposition.  The 
disease  exhibits  a  proneness  to  select  as  victims  hard  students,  indi- 
viduals accustomed  to  sedentary  pursuits,  those  who  follow  certain 
unfavorable  occupations,  and,  finally,  persons  subjected  to  arbitrary 
confinement  in  prisons  and  other  detention  institutions.  The  undue 
preponderance  of  consumption  among  these  people  and  amid  such 
conditions  is,  to  say  the  least,  strongly  suggestive  of  a  predisposing 
influence.  The  development  of  the  disease  among  athletes  and  individ- 
uals apparently  in  the  very  prime  of  health  and  vigor  constitutes  no 
argument  in  opposition  to  the  etiologic  significance  of  a  suitable  soil. 
While  such  instances  occasionally  attain  a  conspicuous  prominence, 
they  are,  upon  the  whole,  quite  exceptional.  The  inference  is  strong 
that  in  athletes  accustomed  to  heroic  feats  of  overexertion  there  may 
exist  a  certain  pathologic  disturbance  of  normal  conditions  materially 
favoring  the  development  of  tuberculosis.  Certain  it  is,  as  a  matter 
of  clinical  experience,  that  an  infection  once  established  in  such  cases 
is  almost  sure  to  pursue  an  unfavorable  course.  It  has  been  my  obser- 
vation that  no  class  of  patients  exhibits  less  power  of  resistance  to  the 
ravages  of  consumption  than  the  athlete  or  hard-working  farmer.  In 
like  manner  the  prevalence  of  pulmonary  tubercidosis  among  the  inmates 
of  prisons  and  reformatories  has  been  frequently  cited  as  an  overwhelm- 
ing example  of  the  danger  of  transmitting  the  disease  from  one  per- 
son to  another.  It  is  apparent  that  there  is  a  tendency  to  disregard 
the  predisposing  influence  of  confinement,  lack  of  sunshine,  fresh  air, 
exercise,  proper  food,  contentment,  high  ideals,  and  incentives  to  work. 
It  is  interesting  to  note,  from  a  review  of  statistics,  that  the  pi'opagation 
of  the  disease  in  prisons  is  not  noticed  as  much  among  those  who  are 
allowed  a  portion  of  their  liberty  as  among  those  subjected  to  solitary 
confinement  or  imprisoned  for  a  part  of  the  day  within  the  confines  of 
a  narrow  cell.  It  would  appear  that  if,  regardless  of  environment,  the 
presence  of  the  bacillus  was  the  sole  consideration,  the  greatest  develop- 
ment of  consumption,  on  account  of  the  exceptional  opportunities  for 
infection  through  personal  contact,  should  take  place  among  convicts 
who  are  permitted  to  mingle  more  or  less  in  crowded  workshops.  The 
fact  that  the  spread  of  the  disease  in  these  institutions  relates  particu- 
larly to  those  who,  through  their  segregation,  are  less  exposed  to  the 
dangers  of  infection,  adds  corroborative  evidence  as  to  the  predisposing 
influence  of  an  unfavorable  environment. 

Attention  has  been  called  to  the  fact  that,  prior  to  1864,  consumption 
was  comparatively  rare  among  the  negroes,  partly  because  of  the  few 
sources  of  infection,  but  more  particularly  because  of  their  outdoor 
existence,  obligatory  physical  exercise,  abundance  of  suitable  food, 
and  the  general  contentment  and  peace  of  mind  incident  to  life  in  the 
quarters.  Upon  being  compelled  to  care  for  themselves,  for  which 
they  were  very  imperfectly  adapted  by  previous  training,  there  was 
imposed  a  necessary  assumption  of  oppressive  responsibilities.  The 
country  air  was  changed  in  many  instances  to  the  less  pure  atmosphere 
of  large  cities,  and  was  often  foully  contaminated  by  their  crowding 
together  in  small  apartments.  In  the  absence  of  enforced  work  in  the 
open  air  there  developed  unavoidably  a  tendency  toward  shiftlessness 


CONDITIONS   INFLUENCING   INFECTION    AFTER    EXPOSURE  75 

and  dissipation.  As  a  result  of  insufficient  food,  inadequate  clothing, 
occasional  undue  exposure,  imperfect  ventilation,  and  habits  of  alco- 
holic and  sexual  intemperance  and  disease,  there  has  resulted  a  pro- 
nounced acquired  disposition  to  tuberculosis,  which,  added  to  the 
vastly  greater  sources  of  infection,  has  operated  toward  the  decimation 
of  the  race. 

It  is  true  that  consumption  among  the  American  Indians  was 
unknown  while  they  were  permitted  to  roam  at  will  throughout  their 
natural  domain.  The  later  ravages  of  the  disease  may  not  be  construed 
as  resulting  entirely  from  the  numerous  sources  of  infection  incident 
to  civilized  life,  but  are  dependent  to  some  extent  upon  the  complete 
transformation  in  the  life,  habits,  and  environment  of  the  Indian  him- 
self. As  a  matter  of  fact,  consumption  upon  the  frontier  among  the 
white  people  is  extremely  rare,  and  the  opportunities  for  infection  are 
not  so  numerous  as  at  first  might  be  supposed.  Assuredly  they  are 
not  sufficient  to  explain  alone  the  somewhat  remarkable  spread  of  the 
disease  among  the  Indian  race.  As  with  the  negro,  at  least  a  partial 
explanation  is  found  in  the  lessened  outdoor  existence,  diminished 
exercise,  infrequent  Iniiitiii^  (li\ersions,  marches,  and  marauding  expe- 
ditions, the  greater  rest  ri(  t  ions  ujion  their  liberty,  and  the  inculcation  of 
habits  of  shiftlessness  and  dissipation. 

Still  another  instance  of  the  influence  of  environment  as  a  predis- 
posing factor  in  the  development  of  tul:>erculosis  is  found  in  the  some- 
what surprising  development  of  the  disease  among  soldiers  who  are 
subjected  to  rigid  physical  examinations  before  admission  to  the  armies 
of  the  world.  In  a  report  recently  issued  concerning  the  health  statis- 
tics of  the  United  States  army  for  the  past  calendar  ye^r  it  is  stated  that, 
in  spite  of  the  short  term  of  enlistment  and  their  assumed  normal  con- 
dition upon  entrance  to  the  army,  0.68  per  cent,  of  the  soldiers  suc- 
cumbed to  tuberculosis,  while  5  per  cent,  of  all  the  deaths  in  the 
Philippines  and  20  per  cent,  of  the  discharges  were  occasioned  by  this 
disease.  These  facts  are  not  to  be  attributed  entirely  to  the  confinement 
incident  to  the  barracks  and  the  consequent  opportunities  for  infection. 
An  additional  causal  factor  is  found  in  the  unpleasant  environment, 
as  evidenced  by  the  frequent  desertions,  the  irregularities  in  the  quantity 
or  quality  of  food  and  the  time  of  its  administration,  and  the  fatigue, 
discomfort,  and  exposure  resulting  from  camp  life  and  strenuous 
marches. 

That  occupation  is  an  element  of  some  importance  in  the  causation 
of  consumption  is  shown  by  the  alarming  prevalence  of  the  disease 
among  employes  in  department  stores,  mills,  post-offices,  printing-rooms, 
and  saloons,  in  all  of  which  places  the  ventilation  is  notoriously  inade- 
quate. The  influence  of  occupation  is  still  further  emphasized  by  the 
development  of  tulierculosis  among  millers,  plasterers,  stone-cutters, 
grinders,  potters,  and  other  persons  necessarily  obliged  to  breathe  an 
atmosphere  deficient  in  oxygen,  contaminated  by  noxious  vapors,  or 
impregnated  by  particles  of  impalpable  dust. 

The  influence  of  age  and  race  has  been  discussed  in  previous  chapters. 
Cei-tain  diseases  are  known  to  effect  a  varying  degree  of  predisposition 
to  tuberculosis,  as  measles,  whooping-cough,  bronchitis,  influenza,  and 
typhoid.  It  is  probable  that  in  most  instances  the  tubercle  deposit 
previously  existed  as  a  latent  infection,  a  renewed  activity  being  induced 
on  account  of  the  lessened  resistance  incident  to  the  recent  illness.     The 


76  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

relation  of  the  above  diseases  and  of  pneumonia,  pleurisy,  pulmonary 
hemorrhages,  and  trauma  to  tuberculosis  are  more  properly  suited  for 
discussion  in  other  portions  of  the  book. 

In  adcUtion  to  such  incUvidual  peculiarities  as  age,  inheritance, 
occupation,  envh-onment,  and  previous  diseases,  all  of  which  are  known 
to  influence  infection  to  some  extent,  the  relative  virulence  of  the  bacilli 
and  the  character  of  the  tissues  are  known  to  aid  in  determining  the 
course  of  the  disease.  Variations  in  the  virulence  of  tubercle  bacilli 
are  known  to  exist,  and  it  is  highly  probable  that  essential  differences 
in  the  clinical  manifestations  and  in  the  nature  of  pathologic  changes 
result  from  this  cause.  Another  factor  of  considerable  importance  in 
influencing  infection  is  the  number  of  bacilli  succeeding  in  gaining 
entrance  into  the  body.  In  other  words,  the  resulting  clinical  and 
pathologic  change  may  be  expected  to  correspond  more  or  less  to  the 
dose  of  the  infection,  if  such  a  term  be  permitted,  the  combined  effects 
of  many  bacilli  being  far  more  difficult  to  overcome  than  a  smaU  num- 
ber. The  receptivity  of  the  soil  in  the  particular  portion  of  the  body 
destined  to  be  the  accidental  abode  of  the  bacUlus  is  still  another 
feature  of  moment  in  the  determination  of  the  resulting  infection. 
Growth  and  distribution  are  favored  particularly  in  vascular  tissues  rich 
in  lymphatics  and  with  an  excess  of  moisture.  Looseness  of  texture 
represents  concUtions  eminently  suiteil  to  the  development  and  spread 
of  tuberculosis  as  opposed  to  dense  structures  poorly  supplied  with 
lymphatics.  It  is  thus  inexpedient  to  attribute  the  entire  responsibility 
for  the  character  of  resulting  infection  to  the  individual  upon  the  score 
of  increased  susceptibility,  when  manifestly  the  entire  subsequent  course 
of  the  disease  may  be  dependent  upon  such  accidental  conditions  as 
just  described.  As  previously  stated,  it  is  possible  that  the  clinical 
exhibition  of  supposed  differences  in  vital  resistance  may  be  partly  ex- 
plained by  variations  in  the  virulence  of  the  invading  microorganism. 
It  is  notorious  that  anemic,  poorly  nourished,  and  apparently  enfee- 
bled individuals  often  succeed  in  effectually  overcoming  tuberculous 
infection,  while  others  in  seeming  health  and  vigor,  with  an  apparent 
surplus  of  resisting  power,  rapidly  succumb  to  infection. 


SECTION    II 

Pathologic  Anatomy 


CHAPTER   XTII 

GENERAL  CONSIDERATIONS 

The  morbid  processes  peculiar  to  tuberculosis  may  affect  various 
organs  of  the  body.  In  adults  the  lungs  are  the  parts  generally  involved, 
while  in  children  the  lymphatic  glands,  bones,  and  joints  are  frequent 
seats  of  the  disease.  The  pathologic  conditions  in  tuberculosis  of  the 
meninges,  pleura,  serous  membranes,  lymphatic  glands,  bones,  joints, 


GENERAL    CONSIDERATIONS  77 

intestines,  and  genito-urinary  apparatus  will  be  discussed  in  connection 
with  tuberculosis  of  these  special  regions.  Present  discussion  relates 
solely  to  a  consideration  of  the  various  anatomic  changes  found  in 
tuberculosis  of  the  lungs. 

In  pulmonary  tuberculosis  there  exists  a  striking  variety  of 
pathologic  conditions.  The  essential  morbid  processes  are:  (1) 
The  development  of  minute  nodules  conforming  to  a  fixed  t3'pe 
of  structural  change,  and  known  as  the  true  pathologic  tubercle; 
(2)  the  degenerative  change  peculiar  to  the  tubercle  itself,  includ- 
ing caseation  and  softening;  (3)  the  constructive  processes  within 
and  around  the  tubercle;  (4)  conglomerate  tuliercle  formation;  (5) 
diffuse  tuberculous  infiltration  without  the  development  of  discrete 
nodules;  (6)  secondary  inflammatory  processes  attended  by  their 
various  exudates.  These  latter  infections,  with  their  lesions,  not  infre- 
quently constitute  the  most  conspicuous  gross  anatomic  change, 
the  nodules  appearing  upon  macroscopic  inspection  relatively  incon- 
sequential. In  some  cases  definite  tubercles  are  absent  altogether, 
fulminating  pneumonic  processes  with  speedy  destructive  change  pre- 
dominating over  the  more  characteristic  tubcrclf.  Again,  in  other 
cases,  the  secondary  inflammatory  condition  is  accoiniianicil  liy  exten- 
sive reactive  processes  of  connective-tissue  rciiaii'.  the  exudative  and 
degenerative  lesions  being  comparatively  inconspicuous.  In  this  way 
the  natural  constructive  efforts  are  analogous  to  the  sclerosis  taking 
place  in  the  peripheral  region  of  the  tubercle  itself.  Thus  it  is  seen  that 
the  pathologic  condition  in  the  lungs  of  different  individuals  suffering 
from  pulmonary  tuberculosis  or  in  various  portions  of  the  same  organ 
conforms  to  no  single  anatomic  type.  According  to  the  extent  and 
character  of  the  nioibid  pincess  in  the  pulmonary  tissues  there  may 
result  in  several  p;irts  ol  the  same  lung  striking  differences  in  the  micro- 
scopic and  macroscopic  appearance.  The  only  lesion  which  may  be 
regarded  as  definitely  characteristic  of  tuberculosis  is  the  elementary 
tubercle,  and  even  this,  without  the  presence  of  liacilli,  fails  to  serve 
as  an  absolutely  distinguishing  feature  of  the  di.sease.  Similar  tubercle 
formation  may  be  present  in  syphilis,  and  is  sometimes  produced  by 
other  microorganisms.  It  is  even  claimed  that  pseudotuberculosis  may 
result  from  the  irritation  of  certain  foreign  bodies.  It  is  probable, 
however,  that  in  nearly  all  instances  the  histologic  clianges  are  pro- 
duced by  bacteria,  and  that  by  far  the  most  common  microorganism 
in  such  formation  is  the  tuliercle  liacilliis.  While  in  tuberculosis  the 
true  pathologic  tubercle  constitutes  .-i  cluirartcristic  lesion,  the  presence 
of  bacilli  in  the  tissues  foim-  an  e- eiiiial  condition.  I'uither,  a  genuine 
tubercle  deposit  may  exist  ui  various  poitious  of  the  body  without  the 
affected  tissues  exhibiting  the  definite  histologic  siructnic  of  elementary 
tubercle,  as  commonly  oljserved  in  lupus  \ulga.ris.  AlmIu.  tin-  luKercle 
itself  not  only  may  undergo  certain  evolutionary  changes  either  degenera- 
tive or  constructive,  but  even  in  the  acme  of  its  development  may  exhibit 
important  differences  in  structural  formation,  as  will  be  described  later. 

Until  quite  recently  it  has  been  the  general  belief  of  pathologists 
that  the  mode  of  entrance  of  the  bacillus  into  the  pulmonary  tissues 
has  been  chiefly  by  inhalation  into  the  bronchial  tract.  In  miliary 
tuberculosis  a  general  distribution  of  the  bacilli  to  the  lungs  through 
the  medium  of  the  circulation  has  been  recognized  for  a  long  time. 
While  conveyance  of  the  infective  agent  to  the  pulmonary  tissues  by 


78  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

means  of  the  lymphatic  current  was  known  to  take  place  in  occasional 
instances,  immediate  infection  of  the  lungs  from  aspiration  of  the  bacilli 
has  been  regarded  as  the  much  more  common  method.  In  the  light 
of  modern  investigation,  to  which  reference  has  been  made  in  preceding 
chapters,  it  is  probable  that  the  principal  method  of  bacillary  distribution 
is  through  the  lymphatic  and  vascular  channels.  It  is  known  that 
bacilli  may  traverse  the  mucous  membranes  and  enter  the  circulation 
without  primary  lesion  at  the  point  of  entrance.  Attention  has  been 
called  to  the  rapid  tuberculous  involvement  of  met^enteric  and  bronchial 
glands  following  the  penetration  of  an  intact  intestinal  membrane. 
Shortly  after  test-meals  of  infective  food,  bacilli  have  been  detected  in 
the  thoracic  duct  and  even  in  the  pulmonary  artery.  It  cannot  be 
denied  that  bacilli  may  enter  the  alveolar  tissues  via  the  respiratory 
tract,  the  blood-vessels,  and  the  lymphatic  circulation.  In  pulmonary 
tuberculosis,  irrespective  of  the  precise  mode  of  infection,  it  is  extremely 
difficult  to  discriminate  between  the  ultimate  morbid  conchtions  pre- 
sented in  different  instances.  Therefore,  it  is  obviously  inexpedient 
to  attempt  a  description  of  the  pathologic  findings  based  upon  the 
several  methods  of  invasion.  The  old  belief  that  the  bacilli  are  almost 
always  inhaled  directly  into  the  alveoli  to  set  up  limited  areas  of 
tuberculous  pneumonia,  or  to  pa.ss  between  intact  epithelial  cells  pro- 
ducing tubercle  formation  in  the  peri-alveolar  and  peribronchial  connec- 
tive tissue,  is  entitled  to  less  credence  than  formerly.  The  common 
location  of  elementary  tubercles  in  the  immediate  vicinity  of  the  arterial 
terminals  makes  it  probable  that  primary  localized  lesions  take  place  in 
the  intima  of  the  finer  arterioles  more  frequently  than  has  been  supposed. 
Scattered  tubercle  deposit  in  the  pulmonary  tissues  is  often  recognized 
in  immediate  proximity  to  preexisting  glandular  foci  of  infection,  the 
lymphatics  being  the  obvious  carriers  of  the  bacilli.  In  view  of  the 
relative  infrequency  at  autopsy  of  pulmonary  lesions  without  involve- 
ment of  bronchial  glands  and  the  greater  frequency  of  tuberculosis  of 
the  lymph-nodes  without  pulmonary  infection,  it  is  fair  to  assume  that 
these  constitute  an  important  reservoir  for  the  subsequent  distribution 
of  the  bacilli.  Finally,  on  account  of  the  early  merging  of  the  pathologic 
conditions,  regardless  of  the  method  of  entrance,  into  a  single  lesion, 
i.  e.,  the  elementary  tubercle  with  accompanying  inflammatory  changes, 
it  is  unnecessary  to  emphasize  further  the  so-called  bronchogenic, 
hematogenic,  or  lymphogenic  methods  of  infection. 


CHAPTER    XIV 
HISTOLOGY 


The  structure  of  the  primitive  tubercle  or  nodule  from  which  the 
disease  derives  its  name  is  of  special  interest.  Generally  speaking, 
tuberculosis  begins  with  the  formation  of  a  miliary  tubercle,  which  is  the 
result  of  mild  inflammatory  processes,  in  turn  produced  by  the  irritating 
presence  of  the  bacillus  in  the  tissues.  This  subsequently  undergoes 
varying  degrees  of  degenerative  change.     The  miliary  tubercle,  though 


HISTOLOGY  79 

deriving  its  name  from  its  resemblance  in  size  to  the  millet-seed,  never- 
theless presents  considerable  variation  in  this  respect.  The  size  may 
vary  from  i^j  to  3  millimeters  in  diameter,  in  some  cases  approaching  the 
dimensions  of  a  small  pea.  It  is  usually  a  compound  body,  composed 
of  a  numlier  of  smaller  elementary  tubercles  which  are  sometimes  termed 
"submiiiary."  From  ten  to  fifty  or  more  of  these  smaller  tubercles 
may  unite  to  form  a  single  miliary  tubercle.  The  term  "submiiiary" 
is  often  applied  to  large  tuberculous  masses  formed  by  the  coalescence 
of  many  miliary  tubercles,  but  it  would  seem  that  the  more  proper 
descriptive  adjective  for  such  confluence  of  tubercles  would  be  "  conglom- 
erate," rather  than  "submiiiary."  ' 

The  true  elementary  tubercle  is  a  small,  non-vascular,  translucent 
nodule,  containing  tubercle  bacilli  and  usually  characterized  by  giant- 
cells,  epithelioid  cells,  and  lymphoid  cells  contained  within  a  reticulum 
of  fibrous  tissue.  The  tubercle  bacillus  is  almost  the  sole  irritative 
influence  capable  of  producing  this  characteristic  cellular  proliferation. 
The  series  of  events  leading  to  this  tubercle  formation  is  undoubtedly 
more  complex  than  is  at  once  apparent.  It  is  believed  that  when  the 
bacilli  first  obtain  lodgment  in  a  favorable  nidus  for  growth  and  de- 
velopment, they  are  rendered  somewhat  inert  by  a  protective  envel- 
ope which  is  later  removed,  permitting  multiplication  of  bacilli  and 
proliferation  of  cells.  The  latter  increases  in  proportion  to  tlic  niul- 
tifJlication  and  irritating  effect  of  the  bacilli.  The  nmltiiilication,  in 
turn,  is  checked  to  a  certain  extent  by  the  excessive  cell  division  whicli 
it  has  succeeded  in  stimulating.  The  bacilli  continue  to  multiply  and 
the  cells  to  increase  up  to  the  point  of  such  peripheral  connective-tissue 
formation  as  suffices  to  produce  a  protective  and  inclusive  barrier, 
within  which  some  of  the  bacilli  are  destroyed  liy  tlie  phagocytic  cells. 
The  cellular  proliferation  may  be  essentially  ciiilliclioidal  or  lymphoidal, 
according  as  the  cells  are  derived  from  the  connect i\e  tissues  or  result 
from  an  infiltration  of  leukocytes  from  surrounding  blood-vessels.  The 
inflow  of  wandering  leukocytes  responds  to  the  local  irritative  effect 
of  the  bacilli  upon  the  vascular  system,  and  as  this  influence  predomi- 
nates, the  cellular  infiltration  is  proportionately  lymphoidal.  As  a  rule, 
however,  the  early  reactive  influence  upon  the  tissues  as  a  result  of  the 
local  irritation,  is  a  proliferation  of  the  fixed  connective-tissue  cells  and 
the  endothelial  cells  of  the  blood-  and  the  lymph-vessels.  Both  the 
epithelioid  and  lymphoid  cells  are,  as  a  rule,  mononuclear,  in  contra- 
chstinction  to  the  giant-cells  which  later  appear.  The  nuclei  of  the 
epithelioid  cells  stain  but  faintly,  while  the  nuclei  of  the  round-cells 
stain  much  more  deeply  and  have  a  smaller  pioiophismic  body.  While 
in  some  instances  the  epithelioid  cells  nia\  incdoniinate  and  in  others 
the  lymphoid,  it  commonly  happens  that  the  loiinei-  cells  are  more  within 
the  tubercle  structure  and  the  latter  in  the  peiiplieial  |i:irts.  The  giant- 
cells  form  an  important  characteristic  ol'  tulieicle  lormalion,  and  are 
known  to  occur  in  other  conditions  than  tuberculosis,  notably  in  the 
granulomata  and  in  sarcoma.  They  are  large,  oval,  or  circular  pro- 
toplasmic masses  containing  multiple  nuclei.  These  are  sometimes 
grouped  at  the  two  extremities  of  an  oval  cell  constituting  the  so-called 
bipolar  arrangement  of  nuclei,  and  are  often  disposed  circularly  within 
the  giant-cell  around  its  outer  margin.  Several  theories  have  been 
off'ered  in  explanation  of  the  formation  of  giant-cells.  According  to 
Councilman,  they  may  result  from  the  coalescence  of  several  epithelioid 


SU  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

cells,  or  from  division  of  nuclei  without  division  of  the  protoplasm,  or 
from  proliferation  around  a  thrombus  of  entlothelial  cells  of  the  blood 
or  lymphatic  vessels.  Metchnikoff  believes  in  their  origin  from  a  fusion 
of  epithelioid  cells,  while  Baumgarten  adheres  to  the  belief  of  their 
development  from  multiple  division  of  the  nucleus  of  a  fixed  tissue-cell. 
The  giant-cells,  which  are  considered  by  Metchnikoff  to  be  active  agents 
of  defense,  often  vary  considerably  in  number  in  inverse  ratio  to  the  ba- 
cilli. It  is  recognized  that  in  tuberculosis  of  lymphatic  glands,  of  bones 
and  joints,  and  in  lupus,  the  giant-cells  are  numerous,  w-hereas  the  bacilli 
are  few.  In  miliary  tubercles,  however,  the  reverse  is  the  case.  Bacilli 
may  be  present  in  the  giant-cells  as  well  as  in  the  epithelioid  and  lym- 
phoid cells,  or  between  the  various  cells  in  the  periphery  of  the  tubercle. 
They  are  often  found  in  the  center  "t  the  tubercle  which  is  undergoing 
degenerative  change.     It  has  been  iidtcd  i  hat  when  present  in  giant-cells 


Fig.  1. — Drawing  of  miliary  tuljerule  ui  ilir  -i.lfrn.  Iimjii  case  of  miliary  tuberculosis.  Note 
central  area  of  beginning  necrosis  and  conru-ctiv.  ti--uH  i.fi.  ulum.  Note  the  two  giant-cells,  the 
one  in  the  center  showing  distinctly  pi.>ni)liei:il  ai  lan^.-imnt  ..I  the  nuclei.  Note  further  peripheral 
infiltration  of  the  round-cells. 

they  are  apt  to  congregate  in  the  center  in  the  event  of  a  peripheral  or 
mural  arrangement  of  nuclei,  and  in  case  of  elongated  cells  with  nuclei 
at  one  pole,  to  assemble  at  the  opposite  extremity.  With  advancing 
degeneration  in  the  center  of  the  tubercle  the  bacilli  in  this  region  dis- 
appear as  a  result  of  disintegration  and  death,  the  number  increasing, 
however,  in  peripheral  portions. 

An  important  constituent  of  the  elementary  tubercle  is  a  reticulum 
of  connective  tissue,  which  is  interwoven  between  the  epithelioid  and 
lymphoid  cells,  and  sometimes  appears  to  be  a  branching  extension 
of  the  protoplasmic  areas  characterizing  irregular  giant-cells.  The 
connective-tissue  reticulum  is  much  more  abundant  at  the  periphery 
of  the  tubercle.  The  reticulum  is  thought  to  be  formed  in  part  bj-  the 
fibrination  of  the  protoplasm  of  cells. 


HISTOLOGY  81 

Degenerative  change  is  characteristic  of  tubercle  deposit  and  some- 
times takes  place  early  in  the  evolution  of  the  lesion.  Owing  to  the 
absence  of  newly  formed  blood-vessels,  no  nutriment  is  conveyed  to  the 
tissues  within  the  tubercle.  The  avascular  condition  is  an  important 
cause  of  the  degenerative  change.  Other  factors  responsible  for  its 
production  are  the  specific  effect  of  the  living  tubercle  bacillus  and  the 
toxins.  The  degenerative  processes  consist  of  hyaline  change,  coag- 
ulation necrosis,  a  degree  of  fatty  degeneration,  varying  degrees  of 
caseation,  and  calcification.  The  degenerative  changes  usually  take 
place  early  in  the  central  cells  of  the  tubercle,  sometimes  affecting  the 
giant-cells  before  all  others.  Usually  the  lymphoid  cells  are  transformed 
somewhat  before  the  degenerative  process  attacks  those  of  the  epithe- 
lioid variety,  which  apparently  are  more  resistant  than  other  cells. 
Owing  to  the  excess  of  lymphoid  cells  the  epithelioid  ty|ic  i,-  often  not 
recognized  until  the  former  have  degenerated  and  ( lisapi  K'arcd.  Definite 
caseation  is  preceded  by  a  sliiiht  linuiula.i'  chaii.ue  in  the  protoplasm  of 
the  cells.  With  later  degoiieratiini  the  n\iclci  are  found  more  or  less 
broken  down  and  fragmentary,  with  Ic^scihmI  inclination  to  take  ordinary 
stains.  Some  authors,  however,  June  imictl  a  bright  staining  reaction 
of  the  nuclei  even  in  the  midst  of  in'cn  ii  ic  il:ani;e.  The  contour  of  the 
cells  becomes  defined  less  sharply  uniil  I'r  oiitHiies  are  lost  altogether, 
the  affected  portion  of  the  tiilici<  Ic  imi  i;  tniL^  <>(  a  lidnKiiiciuMius  necrotic 
area.  In  this  manner,  as  a  rcM;!i  "I  roaiiiilat  imi  iiccKi.-i,-.  the  central 
portion  of  the  tubercle  is  traii.-lui  incd  into  a  hrokcn-ilow  n  mass,  con- 
taining, in  addition  to  the  disintegratetl  cells,  living  antl  destroyed  Ijacilli. 
Outside  of  the  caseous  center  there  are  present  epithelioid  cells  ^\■ith 
an  occasional  giant-cell  undergoing  beginning  degeneration,  and  at  the 
periphery  epithelioid  and  lymphoid  cells  icpi-csontinn  the  newer  evolu- 
tion as  a  result  of  cellular  proliln.iiion.  In  uiaiii-crll-  the  degenerative 
change  also  takes  place  in  the  icniei-  of  the  cell,  paiticiihniy  when  the 
nuclei  are  disposed  circularly  at  the  peripliery.  Sten.^cl  and  <ithers  have 
called  attention  to  the  fact  that  when  the  nuclei  occ\ii-  ihiefly  at  one 
pole  of  an  elongated  giant-cell  the  coagulation  necro>is  u.-uallv  takes 
place  at  the  op])osite  ]iole.  It  has  been  previously  stated  that  the 
tubercle  bacilli,  when  lonnd  in  giant-cells,  occur  at  the  center  in  cti.se  of 
peripheral  nuclear  <listiil>ution  and  at  the  pole  opposite  to  the  gathering 
of  nuclei.  It  would  thus  seem  to  be  a  reasonable  conclusion  that  the 
regional  degenerative  change  in  giant-cells  corresponds  closely  to  that 
portion  of  the  cell  in  which  the  bacilli  are  grouped. 

As  the  degenerative  processes  further  advance  the  entire  tubercle 
undergoes  coagulation  necrosis  and  the  process  of  caseation  becomes 
complete.  Leukocytes  are  usually  attracted  in  coiisiilerable  numbers 
to  the  areas  of  degeneration,  where  they  suft'er  the  same  fate  as  the  fixed 
cells.  The  exudative  processes  and  the  resulting  caseation  are  not  con- 
fined to  the  tissue  within  the  tubercle.  This  phase  of  the  subject  will  be 
con.sidered  more  fully  in  connection  willi  diffu.se  tuberculous  infiltration 
and  the  secondary  inflammatoi\-  h-ion^.  Of  .■ill  the  tis.-^ues  in\ol\ed  in 
the  structure  of  tubercle,  the  hi  iron-  reticulum  is  the  niosi  l(■^i^lant  to 
degeneration.  Connective-tissue  proliferation  may  remain  active  in  the 
periphery  of  the  tubercle,  and  eventually  produce  a  surrounding  fibrous 
barrier  delimiting  the  tuberculous  process  and  entirely  encapsulating  the 
tubercle  itself. 

It  will  be  seen,  however,  that  the  reactive  connective-tissue  hyper- 
6 


82  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

plasia  is  not  always  sufficient  to  effect  a  complete  encapsulation,  oppor- 
tunity being  afforded  in  many  instances  through  the  lymph-channels, 
and  as  a  result  of  wandering  phagocytes,  for  the  deposit  of  bacilli  in 
fresh  tissue  areas.  Occasionally  it  does  happen  that  the  proliferation 
of  connective  tissue  is  sufficient  to  wall  off  entirely  the  tuberculous  area 
and  to  produce  decided  contraction  change.  The  fibrosis  eventually 
may  involve  the  central  portion  of  the  tubercle  as  well  as  the  surrounding 
parts.  As  a  result  of  such  reorganization  small  foci  of  infection  may  be 
converted  into  dense  cicatricial  tissue  comparativel}'  devoid  of  blood- 
vessels, and  producing  an  eventual  healing  of  the  involved  area.  These 
constructive  efforts  on  the  part  of  the  tissues  constitute  the  only  means 
of  securing  a  permanent  arrest  of  the  disease,  if  not  obliteration  of  the 
tuberculous  lesion.  It  is  generally  thought  that  even  the  formation  of 
tubercle  is  a  natural  conservative  process,  although  for  the  time  being 
admittedly  destructive  in  nature.  To  the  extent  that  the  bacilli  are 
inclosed  or  imprisoned  effectually  within  an  encircling  defensive  wall 
the  process  of  tubercle  formation  with  associated  sclerotic  change  may 
assuredly  be  regarded  as  an  effort  on  the  part  of  the  organism  toward 
self-protection.  Although  this  mechanism  of  defense  is  often  somewhat 
imperfect,  it  is  true  that  the  channels  of  escape  for  the  bacillus  are  .suscep- 
tible of  complete  occlusion  by  active  cellular  proliferation  with  dense 
connective-tissue  encapsulation.  This  reactive  protective  effort  of  the 
invaded  tissues  is  usually  accepted  as  representing  an  inherent  defensive 
action  on  the  part  of  the  animal  organism.  Theobald  Smith,  however, 
believes  that  there  is  a  reciprocal  protective  action  between  the  l)acilli 
and  the  normal  tissues,  and  ascribes  the  process  of  tubercle  formation, 
with  resulting  connective-tissue  proliferation,  to  an  effort  on  the  part 
of  the  parasite  to  obtain  an  abode  where  it  may  sojourn  unmolested 
for  intlefinite  periods. 

While  the  bacillus  undoubtedly  affords  the  stimulus  for  the  cellular 
proliferation,  it  would  appear  that  the  connective-tissue  formation 
constitutes  rather  a  mechanism  of  defense  of  the  tissues  against  the 
invading  parasite.  It  is  apparent  that  the  measure  of  the  practical 
efficiency  of  the  connective-tissue  hyperplasia  depends  upon  the  rate 
of  its  formation.  In  the  evolution  of  tubercle  there  are  present  tu'o  well- 
defined  opposing  forces,  the  eventual  supremcLcii  of  one  denoting  tissue 
repair  and  rrrnn-rii.  thr  other,  progressive  degeneration  and  bacillary  distri- 
bution to  suri-))iiiiiliii(i  jiiiiis.  Upon  the  one  hand,  there  is  a  tendency  for 
active  cell-iinilifei:iti(>ii  with  fibrous  tissue  construction  and  encapsula- 
tion; upon  tlie  other,  advancing  caseation  and  extension  of  the  infection 
to  new  areas  beyond  the  limits  of  peripheral  connective  tissue.  The 
situation  resolves  itself,  therefore,  into  a  race  between  the  effort  of  con- 
struction and  the  tendency  to  destruction,  the  final  issue  being  decided 
according  to  the  relative  rapidity  of  the  contending  processes.  The 
same  inclination  to  degeneration  and  to  connective-tissue  hyperplasia 
is  observed  in  surrounding  areas  and  even  in  diffuse  tuberculous  infiltra- 
tion, large  masses  of  involved  tissue  exhibiting  varying  degrees  of 
necrotic  and  proliferative  change. 

An  extension  of  the  process  from  the  initial  tubercle  takes  place  as 
a  result  of  the  penetration  of  the  connective-tissue  wall  by  the  bacilli 
and  the  peripheral  formation  of  miliary  tubercles.  In  the  same  manner, 
from  these  .secondary  tubercles,  new  centers  of  growth  are  again  formed. 
Not   infrequently   nodules   are   produced   consisting   of   many   miliary 


tubercles  which,  as  caseation  advances  in  the  center,  become  fused  into 
large  masses  of  broken-down  tuberculous  material,  commonly  called 
conglomerate  tubercles,  although  by  some  the  term  "submiliary"  is 
employed.  To  such  masses,  which  sometimes  attain  the  size  of  a  hen's 
egg,  the  appellation  "  crude  tubercle' '  was  applied  by  Laennec.  The 
same  processes  of  degeneration  and  repair  which  take  place  in  a  single 
elementary  tubercle  also  obtain  in  all  the  constituent  tubercles  compris- 
ing the  entire  mass.  Caseation  and  softening  with  resulting  excavation 
may  develop  as  a  result  of  the  coalescence  of  the  individual  tubercles, 
or  a  firm  network  of  fibrous  tissue  hyperplasia  may  supervene  in  others. 
The  destructive  tendency  toward  cavity  formation  not  only  involves 
structures  of  tuberculous  formation,  but  often  invades  pneumonic  areas 
resulting  from  secondary  inflammatory  changes.  Factors  of  great 
importance  in  such  cases  are,  first,  the  nature  of  the  exudative  process, 
which,  though  purulent,  is  not  necessarily  due  to  mixed  infection,  and, 
second,  the  invasion  of  these  pneumonic  areas  with  tubercle  bacilli. 
Even  in  tubercle  formation,  without  other  associated  inflammatory 
lesions,  there  is  usually  an  abundant  exudation  which  may  consist  either 
of  polynuclear  leukocytes  or  of  serum.  The  exudation  sometimes  is 
fibrinous  and  may  invade  the  caseous  tissue  or  cover  the  surface  of 
miliary  tubercles.  The  exudate,  of  whatever  character,  though  external 
to  the  tubercle  itself,  may  be  distributed  extensively  in  the  surrounding 
tissue,  and  considerably  augment  the  size  of  nodules  or  conglomerate 
tubercles.  Discrete  tuberculous  nodules  are  often  absent  altogether, 
and  in  their  place  there  may  exist  a  diffuse  tuberculous  infiltration  con- 
taining numerous  giant  and  epithelioiil  cells,  with  varying  degrees  of 
caseation  and  fibrosis.  In  addition  to  the  necrotic  and  sclerotic  changes 
possible  of  development  in  individual  tubercles  or  in  a  conglomerate 
mass,  the  process  of  calcification  occasionally  ensues.  This  takes  place, 
however,  only  after  the  formation  of  considerable  connective-tissue 
proliferation.  The  bacilli  are  much  more  frequent  in  the  broken-down 
debris  of  these  diffuse  processes  after  softening  has  become  advanced 
than  in  the  strictly  caseous  material.  The  content  of  the  softened 
tuberculous  mass  is  ;i  thick,  creamy,  yellowish  material,  somewhat 
re.sembling  pus,  thoimh  (liffciing  from  it  histologically.  There  are 
present  much  granular  debris,  broken-down  cells,  and  fat-drops. 

In  tuberculosis  of  the  lungs,  on  account  of  the  opening  of  tuberculous 
cavities  into  bronchi,  the  conditions  are  favorable  for  the  entrance  of 
numerous  pyogenic  bacteria.  In  pulmonary  tissues  the  characteristic 
tubercle  formation  previously  described  is  limited  somewhat  by  the 
loose  anatomic  structure  of  the  parts.  The  tissue  is  not  sufficient  in 
extent  nor  of  such  character  as  to  permit  the  fullest  elaboration  of  tubercle 
formation,  although  extensive  hyperplasia  occurs  in  surrounding  areas. 
Exceptional  opportunities  are  afforded,  however,  for  dissemination  of 
the  tuberculous  infection  by  the  physiologic  motion  of  the  parts,  the 
penetration  of  brondii,  :inil  tlic  luxnri;nit  network  of  lymphatic  channels 
and  blood-vessels.  While  the  in(i\("iiieiits  of  ordinary  respiration  must 
be  regarded  to  some  extent  as  ininueal  to  rapid  tissue  repair,  the  deep 
inspiratory  efforts  attentling  violent  attacks  of  coughing  are  assuredly 
instrumental  in  further  distribution  of  the  liacilli  throughout  the  respira- 
tory tract. 

A  most  important  feature  of  tuberculous  infection  of  the  pulmonary 
tissues  is  the  frequent  extensive  development  of  secondary  inflammatory 


84  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

lesions.  The  most  perfect  example  of  typical  tubercle  formation  in 
the  lungs  is  found  in  miliary  tuberculosis,  although  even  in  such  cases 
exudation  is  not  entirely  absent.  The  tubercles  are  found  in  the  walls 
of  the  alveoli,  of  the  bronchi,  and  of  the  blood-vessels.  Areas  of  tuber- 
culous bronchopneumonia  with  extensive  retroactive  inflammatory 
change  are  sometimes  accompanied  by  miliary  tubercles.  These  inflam- 
matory lesions,  dependent  largely  upon  exudative  processes,  may 
partake  of  the  nature  of  catarrhal  or  fibrinous  pneumonia,  and  in 
exceptional  instances  give  rise  to  marked  proliferation  of  connective 
tissue,  inducing  pronounced  contraction  change.  The  areas  of  pneu- 
monic involvement  may  ^■ary  greatly  in  size,  sometimes  the  process 
being  confined  to  tiny  areas,  in  other  instances  being  distributed  through- 
out a  single  lobe  or  an  entire  lung.  Extensive  areas  may  be  affected 
simultaneously,  or  adjacent  foci  maj"  subsequently  become  confluent. 
Caseation  may  super\-ene  precisely  as  described  in  connection  with  the 
elementary  tubercle.  The  degenerative  change  may  involve  wide  areas 
of  pulmonary  tissue  or  appear  in  the  form  of  cUscrete  foci  of  necrosis. 
The  inflammatory  process  sometimes  involves  the  wall  of  the  bronclii 
as  well  as  pulmonary  tissue.  Caseation,  either  with  or  without  the 
formation  of  genuine  tubercle,  may  develop  within  the  wall,  resulting 
in  its  eventual  penetration  and  communication  with  pulmonary  cavities. 
The  process  of  excavation  maj'  be  astonishingly  rapid  in  areas  of  pneu- 
monic consolidation,  the  destruction  of  tissue  sometimes  extending 
into  and  through  the  walls  of  several  bronchi.  The  rapidity  of  the 
softening,  with  added  increase  in  the  size  of  the  pulmonary  excavation, 
is  tlependent  largely  upon  the  character  of  the  tissue  comprising  its 
encircling  wall.  If  the  wall  of  the  cavity  consists  of  an  area  of  tuber- 
culous pneumonia,  further  excavation  is  much  more  likely  than  if  the 
adjacent  tissue  consists  of  elementary  tubercle  formation  or  chronic 
tuberculous  infiltration,  in  which  event  the  contUtions  are  much  more 
favorable  for  limiting  cavity  formation.  Thus  the  remarkable  diversity 
in  the  rapiditj-  and  extent  of  cavity  formation  is  explained  almost 
entirely  by  the  character  of  the  contiguous  tissue.  It  is  not  to  be 
understood  that  pulmonary  excavation  must  necessarily  be  accompanied 
by  rapid  softening,  copious  expectoration,  increase  of  bacilli  in  the 
sputum,  temperature  elevation,  or  general  decline,  although  such  clin- 
ical manifestations  are  common.  Neither  is  it  always  true  that  cavity 
formation  is  a.ssociated  with  further  dissemination  of  tubercle  bacilli. 

The  development  of  pulmonary  hemorrhage  is  not  always  occasioned 
by  a  destructive  tuberculous  change  involving  the  wall  of  the  blood- 
\essels,  although  some  are  probably  attributable  to  its  caseation 
and  rupture.  In  the  event  of  cavity  formation  with  removal  of 
the  support  of  the  arterial  wall,  aneurysmal  dilatation  not  infrequently 
results.  Rupture  subsequently  takes  place  by  reason  of  purely  mechan- 
ical causes,  without  definite  tubercle  deposit  in  the  wall  of  the  artery. 
The  small  hemorrhages  so  frequently  oliserved  in  all  stages  of  tuberculo- 
sis, sometimes  even  in  advance  of  physical  signs,  would  seem  somewhat 
difficult  of  explanation,  becau.se  in  areas  of  tuberculous  deposit  with  or 
without  caseation  and  excavation  the  small  bloofl-vessels  are  obliterated. 
It  is  known,  however,  that  the  surrounding  blood-vessels  which  make  up 
the  collateral  circulation  are  engorged  to  a  considerable  extent,  and 
at  times  of  temporary  excitement  or  strain  are  incapable  of  withstanding 
the  intra-arterial  pressure. 


GROSS    APPEARANCES 


CHAPTER   XV 
GROSS  APPEARANCES 


The  macroscopic  appearance  of  tuberculous  pulmonary  lesions 
varies  remarkably  according  to  the  course,  duration,  type,  and  compli- 
cations of  the  disease.  While  degenerative  change  may  be  said  to 
constitute  the  chief  pathologic  characteristic  of  pulmonary  consumption, 
there  are  present  in  many  cases  featuies  of  essential  importance  aside 
from  recognized  areas  of  necrosis.  These  consist  of  miliary  tubercles 
and  of  differing  degrees  and  extent  of  pneumonic  consolidation,  catarrhal 
inflammation,  caseation,  cavity  formation,  calcification,  fibrosis,  com- 
pensatory emphysema,  atelectasis,  both  from  compression  and  from 
local  occlusion  of  bronchioles,  pleural  inflammation  with  tubercle  deposit, 
thickening,  adhesions,  perforation,  and  resulting  pneumothorax.  In 
addition  to  these  conditions  of  pathologic  interest  incident  to  the  inva- 
sion of  the  bacillus,  there  is  exhibited  a  wide  divergence  in  different  cases 
in  the  amount  of  connective-tissue  proliferation.  This  may  be  compar- 
atively slight  or  alispiit  ;ilto,cTthcr,  pnvticularly  in  cases  of  the  acute 
pneumonic  type — tlic  sn-calli'd  tulicrciilcius  pneumonia.  Upon  the 
other  hand,  the  coniHMti\(-iissuc  liy])ciphisia  is  well  marked  in  the  more 
chronic  cases  of  ca.>eoiiljruid  pulmonary  tuberculosis,  and  not  infre- 
quently becomes  a  conspicuous  anatomic  feature,  as  in  fibroid  phthisis. 
In  the  same  manner  other  pathologic  conditions  are  subject  to  consider- 
able variation  in  differing  groups.  The  degenerative  change  may  be 
rapid  and  extensive,  with  speedy  formation  of  cavities,  or  slow  and 
unaccompanied  by  recognized  destruction  of  tissue,  the  process  of  repair 
being  continually  maintained  in  minute  centers  of  infection.  Generally 
speaking,  the  caseous  degeneration  is  more  marked  in  acute  cases,  in 
which  it  sometimes  appears  as  an  early  pathologic  manifestation.  The 
necrotic  changes  leading  to  cavity  formation,  though  present  both  in 
acute  and  in  chronic  cases,  are  not  ahrays  exhibited  in  acute  pneumonic 
phthisis  on  account  of  its  7'enj  rapid  developynent  and  brief  duration.  In 
this  disease  the  early  consolidation  overshadows  all  other  conditions 
and  often  imparts  but  the  clinical  aspect  of  either  an  ordinary  catarrhal 
or  fibrinous  pneumonia,  the  victims  sometimes  succumbing  before  the 
development  of  extensive  cavity  formation.  In  miliary  tuberculosis 
the  degenerative  process  is  present  in  disseminated  tubercles,  which 
are  changed  from  almoist  invisible,  gray,  translucent  specks  into 
opaque,  yellowish  spots.  In  such  ca.ses  gross  areas  of  softening  and 
excavation  are  seldom  observed,  on  account  of  the  rapid  progress  of  the 
disease  to  a  fatal  termination.  It  is  true  that,  exclusive  qf  genuine 
miliary  tuberculosis,  fresh  miliary  tubercles  may  be  present  in  associa- 
tion with  large  areas  of  pneumonic  consolidatinn  oi'  \\\\\\  ma.sses  of 
caseous  degeneration,  but  in  such  instance-^  the  tulicrclc  does  not  form 
the  e.ssential  or  characterizing  pathologic  ((uidition.  Though  tubercles 
are  often  found  along  the  edges  of  consolidated,  cheesy,  or  necrotic 
tissue,  the  macroscopic  appearance  of  the  iuxohcd  lung,  as  a  whole,  is 
entirely  different  from  that  exhibited  in  miliary  tuljercuiosis. 

Again,  pneumonic  consolidation,  although  present  in  differing  de- 
grees in  almost  all  cases  of  pulmonary  tuberculosis,  and  even  to  some 


86  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

extent  in  the  midst  of  disseminated  miliary  tuberculosis,  is  not  invariably 
a  distinguishing  feature.  The  pneumonic  process  may  be  confined  to 
small  areas  in  the  immediate  vicinity  of  the  affected  alveoli  or  be  diffused 
throughout  an  entire  lobe  or  lung.  In  acute  pneumonic  phthisis  the 
exudation  constitutes  the  predominant  pathologic  characteristic,  whether 
the  process  appears  as  a  distinct  lobar  affection  or  as  a  lobular  involve- 
ment vvith  more  or  less  tendency  toward  the  confluence  of  solidified  areas. 
In  miliary  tuberculosis,  however,  the  pneumonic  condition  is  defined 
much  less  sharply  and  is  usually  quite  subordinate  to  the  diffusion  of 
tubercles  in  the  connective  tissue  in  the  vicinity  of  the  fine  arterial  tenni- 
nals.  As  a  rule,  the  consolidation  is  more  apparent  in  cases  conforming 
to  the  florid  type  of  consumption  than  in  the  more  chronic  varieties. 
In  chronic  fibroid  phthisis  the  pneumonic  process  is  subject  to  consider- 
able variation  in  degree  and  distribution.  The  consolidation  is  often 
limited  to  the  apex,  and  is  sometimes  present  only  in  small  areas  of 
lobular  involvement.  In  other  cases  the  pneumonic  process  is  pro- 
nounced, extensive  regions  becoming  progressively  consolidated.  The 
formation  of  tubercles  in  the  connective  tissue  may  give  rise  to  but  slight 
secondary  exudative  change,  and  consequently  to  comparatively  little 
inflammatory  consolidation.  In  other  instances  there  is  an  early  and 
rapid  development  of  caseous  pneumonia,  which,  originating  in  the 
alveoli,  is  capable  of  considerable  extension  to  contiguous  tissues.  In 
cases  without  gross  pneumonic  consolidation  material  ilifferences  exist  in 
the  intensity  of  the  catarrhal  inflammation  involving  the  alveoli  and  finer 
bronchi  in  close  proximity  to  the  tubercle  deposit.  As  previously 
stated,  the  walls  of  either  may  be  the  seat  of  tuberculous  infection. 
Without  exhibiting  definite  tuberculous  lesions,  they  may  be  filled  with 
an  exudation  arising  from  the  inflammatory  condition  incident  to  the 
neighboring  tuberculous  focus.  There  may  exist  a  tlisproportionate 
catarrhal  affection  either  of  the  bronchi  or  of  the  alveoli.  Essential 
differences  in  the  gross  pathologic  appearance  may  arise  from  the  nature 
and  extent  of  the  pleural  involvement.  There  may  be  distributed  upon 
the  surface  miliary  tubercles,  with  or  without  local  inflammatory  change. 
A  simple  congestion  of  the  surface  sometimes  corresponds  to  the  area 
of  pulmonary  disease.  In  other  cases  an  exudative  process  involves 
both  visceral  and  parietal  layers,  which  subsequently  become  aggluti- 
nated and  enormously  thickened.  As  further  organization  of  the  pro- 
duct of  inflammatory  action  takes  place,  extensive  contraction  changes 
develop,  involving  pulmonary  tissues,  adjacent  organs,  and  the  chest- 
wall.  Pleural  effusion  or  empyema  occasionall)'  results  from  infection 
of  the  pleural  surfaces.  Pneumothorax  incident  to  perforation  of  the 
pleura  produces  varying  degrees  of  pulmonary  collapse  and  secondary 
infection. 

From  the  preceding  considerations  it  is  apparent  that  there  is  no  absolute 
unity  of  the  gross  pathologic  lesions  in  pulmonary  tuberculosis,  although 
the  histologic  identity  of  the  primary  tubercle  has  been  long  since  beyond 
dispute.  As  will  be  seen  in  the  accompanying  illustrations  (Plates  3-9), 
inspection  of  the  pulmonary  tissue  in  some  cases  may  disclose  but  slight 
visual  deviation  from  normal  conditions,  while  in  others  the  entire  lung 
may  be  transformed  into  an  unsightly  mass  exhibiting  in  places  miliary 
tubercles,  pneumonic  consolidation,  cheesy  degeneration,  calcification, 
softening  and  cavity  formation,  areas  of  atelectasis,  obliteration  and 
aneurysmal  dilatation  of  the  blood-vessels,  emphysema,  anthracosis. 


PLATE     3- 


Riglit  lung,  showing  well-defined  thickening  of  apical  pleura.  Areas  of  emphysema 
and  bronchopneumonia.  Disseminated  patches  of  antlnacosis  at  base.  Miliary  tuber- 
cles plainly  recognized  on  section  near  lateral  margin  Attciiiiim  is  called  to  Plate  10, 
representing  the  gross  appearance  of  the  left  lung  «(  the  same  iiulividual. 


PLATE    4. 


Eight  lung  from  case  of  miliary  tuberculosis.  Note  extensive  raised  areas  of  emphy- 
sema involving  nearly  ail  portions  of  the  lung.  Note  anomaly  of  iissure.  Note  the 
well-defined  interlobular  septa.  Upon  section,  the  lung  disclo.sed  typical  miliary  de- 
posit. This  lung  was  one-third  larger  than  the  left  lung  from  the  same  individual. 
The  left  lung  was  small,  contracted,  and  bound  down  by  exceedingly  fii-m   adhesions. 


GROSS    APPEARANCES  87 

connective-tissue  iiyperplasia,  and  pleural  thickenings.  In  view  of  the 
wide  range  of  pathologic  conditions,  the  futility  of  any  effort  toward 
a  classic  description  of  gross  pathologic  appearances,  to  be  regarded 
as  typical  of  all  cases  of  pulmonary  tuberculosis,  is  apparent.  Present 
knowledge  derived  from  increasing  experience  in  the  observation,  treat- 
ment, and  autopsy  findings  of  consumption  has  led  to  a  conviction 
of  striking  changes  in  the  anatomic  as  well  as  the  clinical  picture.  In 
spite  of  extensive  destructive  change  representing  large  areas  of  \irulent, 
active  infection  the  processes  of  repair  under  proper  conditions  are  .seen 
to  have  developed  to  an  astonishing  extent.  Conversely,  in  the  midst  of 
excessive  connective-tissue  proliferation,  rapid  changes  of  a  t  ul  lerc-iihius  or 
purely  inflammatory  nature  are  found  to  have  taken  place  witliout  easily 
■explained  cause.  Notwithstanding  the  niultii)li(it y  of  these  pathologic 
conditions  and  the  variability  of  their  ocmuiiciicc,  certain  processes  are 
sufficiently  uniform  to  permit  separate  classification  based  upon  their 
chi-onicity,  gross  appearances,  and  distribution  of  the  lesions  as  follows: 
(1)  Miliary  tuberculosis;  (2)  acute  pneumonic  phthisis  (lobar) ;  (3) 
acute  pneumonic  phthisis  (lobular);  (4)  chronic  caseofibroid  tuberculo- 
sis; (5)  fibroid  phthisis. 

MILIARY  TUBERCULOSIS 

In  miliary  tuberculosis  the  essential  feature  is  the  presence  of  gray, 
translucent  tubercles  in  the  vicinity  of  the  terminals  of  the  pulmonary 
artery.  These  are  often  seen  only  with  some  difficulty  until  after  they 
become  yellow  and  opaque  from  degeneration.  They  sometimes 
increase  in  size,  particularly  as  the  condition  becomes  more  chronic, 
but  this  is  not  very  frequent.  External  to  the  periphery  of  the  miliary 
nodule  there  develops  a  zone  of  catarrhal  inflammation  involving  the 
neighboring  alveoli  and  minute  bronchi.  The  walls  are  infiltrated  with 
an  exudation  of  cells,  become  congested  or  swollen,  and  are  bathed  in  a 
mucopurulent  secretion  which  is  sometimes  partly  hemorrhagic.  In 
proportion  to  the  distribution  of  the  miliary  nodules  the  lung  becomes, 
as  a  whole,  hyperemic,  heavier  than  normal,  somewhat  solidified,  but 
still  containing  some  air.  If  the  consolidation  is  extreme,  the  lung  is 
sufficiently  heavy  to  sink  in  water  and  is  darkly  congested.  The  tissue 
is  rarely  dry  and  friable,  but  is,  as  a  rule,  moist  and  solid  on  section. 
In  chronic  cases  the  degenerative  change  is  pronounced  and  areas  of 
yellowish,  .softened  tissue  are  recognized.  The  nodular  dissemination 
is  often  more  marked  at  the  l:)ases  than  in  the  upper  regions. 

ACUTE  PNEUMONIC  PHTHISIS    (LOBAR) 

In  this  condition  the  early  pathologic  lesions  vary  but  slightly,  if 
at  all,  from  those  of  ordinary  croupous  pneumonia.  There  is  an  early 
simultaneous  involvement  of  many  lobules,  sometimes  sufficient  to 
include  an  entire  lobe  or  the  lung  itself.  There  is  noted  an  intense, 
dark-red  congestion,  suggestive  of  the  pathologic  appearance  in  orchnary 
croupous  pneumonia.  The  pleura  is  dull,  and  may  be  covered  with  a 
thin  exudate.  The  lung  is  heavy  and  airless.  Upon  section,  a  granular 
appearance  may  be  imparted  as  a  result  of  fibrinous  coagulation.  Dis- 
crete miliary  tubercles  may  be  scattered  through  the  consolidated  tissue, 
and  particularly  along  the  edges,  but  not  infrequently  these  are  impossi- 


88  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

ble  of  detection.  With  the  onset  of  degeneration  the  lung  assumes  a 
yellowish  or  grayish  color.  Softening  progresses  rapidly,  and  cavity 
formation  results.  The  excavations  are  sometimes  large,  but  more 
frequently  numerous  small  cavities  are  irregularly  distributed  through 
the  infected  area.  The  softening  and  excavation  are  not  due  wholly  to 
the  breaking-up  of  the  exudate,  as  occurs  during  resolution  in  fibrinous 
pneumonia,  but  is  chiefly  the  result  of  caseation  and  necrosis  of  the  pul- 
monary tissues.  In  this  type  of  acute  tuberculous  pneumonia  but 
little  opportunity  is  afforded  for  the  process  of  repair.  Connective- 
tissue  proliferation  is  rarely  permitted  to  any  extent  on  account  of  the 
acute  onset  and  course. 

ACUTE  PNEUMONIC  PHTHISIS   (LOBULAR) 

The  pathologic  appearances  in  some  respects  are  dissimilar  from 
the  preceding  conthtion.  The  chief  difference  consists  of  the  lobular 
distribution  of  the  early  lesions,  the  areas  of  ccmsolidation  being  identical 
with  those  in  catarrhal  pneumonia.  In  some  cases  the  consolidation 
starts  in  a  small  portion  of  lung  and  exhibits  an  apparent  migratory 
tendency.  Discrete  regions  of  involvement  not  infrequently  become 
confluent,  establishing  a  gradual  conformity  to  the  lobar  form  of  acute 
pneumonic  phthisis,  the  exudation  often  containing  a  considerable 
amount  of  fibrin.  The  cells  are  derived  from  the  exudative  process  and 
from  the  desquamation  and  proliferation  of  intra-alveolar  epithelial 
cells.  Patches  of  pneumonic  consolidation  undergoing  various  degrees 
of  cheesy  degeneration  and  softening  are  unevenly  distributed  over 
portions  of  one  lung  or  of  both,  often  involving  the  bases.  Tuberculous 
masses  vary  considerably  in  size,  and  are  sometimes  separated  from 
one  another  by  intervening  areas  of  crepitant  lung  tissue.  The  infected 
areas  are  at  first  grayish  red,  but  become  opaque  and  yellowish  as  degen- 
eration advances.  Miliary  tubercles  may  or  may  not  be  present,  as  in 
the  lobar  type  of  tuberculous  pneumonia.  The  finer  bronchial  tubes 
upon  .section  are  shown  to  be  filled  with  a  purulent  exudate,  cheesy 
degeneration  taking  place  in  the  surrounding  tissue.  The  areas  of 
caseation  become  larger,  more  moist,  and  softer,  until  iri'egular  excava- 
tions make  their  appearance. 

CHRONIC  CASEOFIBROID  PHTHISIS 

In  this  form  of  tuberculosis  there  may  be  exhibited  in  various  degrees 
all  the  gross  pathologic  lesions  described  in  connection  with  other  varie- 
ties of  pulmonary  consumption.  There  are  found  miliary  tubercles 
consisting  of  a  number  of  submiliary  or  true  elementary  tubercles, 
larger  nodules  of  conglomerate  tubercle  formation,  areas  of  diffuse  tuber- 
culous infiltration,  secondary  inflammatory  lesions  represented  by 
isolated  or  confluent  patches  of  pneumonic  con.solidation,  cheesy  degen- 
eration of  the  tuberculous  tissue,  marked  exudative  processes,  necrotic 
changes  leading  to  cavity  formation,  and,  finally,  a  more  or  less  extensive 
proliferation  of  fibrous  tissue  in  the  infected  areas.  Before  discussing 
these  respective  anatomic  lesions  seriatim,  it  is  well  to  call  attention  to 
the  following  facts:  (1)  On  account  of  the  insidious  and  localized 
development  large  areas  of  consolidation  are  rarely  present  in  early 
stages,  the  process  being  usually  limited  to  a  small  patch  of  tuberculous 


PLATE    5- 


Miliary  tuberculosis  of  lung  from  infant  six  months  old.     Specimen  hardened  in 
formalin.     Note  tubercles  studding  the  pleura — their  irregular  size  and  distribution. 


Section  of  lung  luu'deneil   in   foi'malin, 
Note  calcareous  deposits. 


ing  distribution  of  miliary  tubercle 


Section  ot  lung  hardened  in  formalin,  showing  patches  of  pnenmonie  caseation  at 
lower  region,  with  cavity  formation  in  the  upper  portion.     Note  blood-vessels  traversing 


the  upper  cavity. 


GROSS    APPEARANCES  89 

infiltration  in  the  apical  region.  (2)  Typical  tuberculous  nodules  often 
undergo  characteristic  degenerative  and  reparative  changes,  and  are  found 
in  connection  with  small  localized  areas  of  pneumonic  infiltration  proceed- 
ing from  centers  of  tuberculous  infection.  (3)  The  process  of  degeneration 
is  seldom  rapid,  though  often  progressive  in  character,  excavation  taking 
place,  as  a  rule,  comparatively  slowly.  (4)  Owing  to  the  chronicity  of 
the  course,  opportunity  is  afforded  to  a  greater  or  less  extent  for  con- 
nective-tissue hyperplasia,  the  constructive  and  destructive  processes 
being  maintained  jointly  for  somewhat  prolonged  periods.  In  chronic 
caseofibroid  phthisis  there  may  be  present  small  tuberculous  nodules 
composed  of  a  number  of  elementary  tubercles  involving  the  peri-alveo- 
lar and  peribronchial  tissues,  and  extending  into  the  alveoli  themselves. 
The  finer  bronchioles  and  surrounding  tissues  are  invaded  also  by  an 
exudative  process.  The  terminal  bronchioles  are  occluded  as  a  result 
of  the  secondary  inflammatory  lesion,  which  subsequently  undergoes 
degeneration  jointly  with  the  tubercle  itself.  On  account  of  the  exten- 
sion of  the  infection  to  contiguous  structures  through  the  medium  of  the 
lymphatics  and  by  the  discharge  of  tuberculous  material  into  adjacent 
bronchi,  the  area  of  di.sease  tends  to  increase  progressively  in  size.  As 
a  result  of  the  degenerative  process  the  consolidated  tissue  presents  an 
opaque,  homogeneous,  yellow  appearance,  in  which  the  tubercle  forma- 
tion is  not,  as  a  rule,  perfectly  distinct.  Tubercles  are  often  recognized, 
however,  along  the  edges  of  the  tuberculous  masses  before  the  degenera- 
tive change  has  become  complete.  The  surrounding  involved  area 
is  usually  congested  and  at  least  partially  consolidated.  Upon  cross- 
section  the  lung  may  pre.sent  here  and  there  a  similar  appearance  to 
that  described  in  connection  with  the  more  acute  forms  of  pulmonary 
tuberculosis,  particularly  if  the  process  at  such  points  has  been  at  all 
active.  The  bronchi  may  be  completely  occluded  by  cheesy  or  purulent 
tuberculous  material.  The  lumen  is  not  always  plugged  entirely  with 
cheesy  exudate,  and  a  small  orifice  can  sometimes  be  detected  in  the 
center  of  a  tuberculous  nodule  undergoing  caseous  degeneration.  If 
the  bronchial  tube  is  cut  longitudinally,  it  may  be  found  filled  with 
broken-down  tuberculous  detritus.  These  masses  of  diseased  tissue 
undergoing  cheesy  degeneration  correspond  to  the  so-called  crude  tulier- 
cle  of  Laennec,  and  may  attain  a  diameter  of  one  to  two  inches.  The 
secondary  inflammatory  processes  in  the  neighborhood  of  tuln'iculous 
foci  are  sufficient  in  some  cases  to  produce  extensive  confluent  arc:is  of 
consolidation,  as  in  the  more  acute  forms  of  pulmonary  iinohcnicnt. 
The  infiltrative  process  may  present  the  appearance  of  red  hepatization 
in  portions  of  the  lung,  while  in  other  places  the  evidence  of  degenerative 
change  is  very  apparent.  Areas  of  pneumonic  consolidation  not  under- 
going degeneration  sometimes  exhibit  a  granular  or  gelatinous  aspect. 

Another  form  of  pneumonic  consolidation  results  from  hemorrhage 
occurring  in  the  course  of  chronic  pulmonary  tuberculosis.  The  blood 
is  frequciifl\-  ill^pired  into  the  finer  bronchi  and  alveoli,  and  not  only 
diminislus  t.i  .-i  cou.siderable  extent  the  respiratory  capacity,  but  also 
favors  the  ili'M'liipment  and  growth  of  secondary  pathogenic  micro- 
organisms. A  diffuse  non-tuberculous  bronchopneumonia  (.septic") 
often  ensues,  and  occasionally  gangrene. 

Pulmonary  excavation  constitutes  a  characteristic  lesion  of  pulmo- 
nary tuberculosis,  and  exhibits  marked  differences  in  size,  rapidity 
of  development,  and  in  the  nature  of  the  tissues  constituting  the  encir- 


90  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

cling  wall.  As  previously  explained,  the  degenerative  process  leading 
to  cavity  formation  may  take  place  in  the  pulmonary  tissues  and  finally 
extend  to  the  wall  of  a  bronchus,  which  subsequently  ulcerates  and 
permits  the  evacuation  of  the  liquefied  contents.  At  other  times  the 
excavation  originates  with  the  dilatation  of  a  bronchial  tube  the  walls 
of  which  yield  to  the  nutritive  and  necrotic  changes  accompanying 
stagnating  secretions.  Other  elements  in  the  formation  of  the  bron- 
chiectatic  condition  are  intrabronchial  pressure  due  to  very  violent  par- 
oxysmal attacks  of  coughing,  and  in  some  instances  to  traction  exerted 
upon  the  external  wall  as  a  result  of  surrounding  fibroid  change.  The 
dilatation  is  also  facilitated  in  many  cases  by  necrotic  changes  in  the 
surrounfling  pulmonary  tissue.  As  dilatation  advances  ulceration  of 
the  wall  takes  place,  accompanied  by  extension  of  the  necrosis  into 
the  contiguous  pulmonary  tissue,  and  further  excavation  ensues.  The 
initial  tuberculous  process  sometimes  invades  the  wall  of  the  bi-onchus, 
producing  perforation  and  extension  to  surrounding  tissues.  Pulmo- 
nary cavities  frequently  become  the  seat  of  secondary  infection,  which 
further  facilitate  the  process  of  destruction.  Increase  of  size  occurs  as 
the  result  of  a  progressively  extending  degeneration  and  necrosis  in  the 
vicinity  of  a  single  cavity,  or  by  the  fusion  of  several  smaller  excavations. 
A  series  of  cavities  sometimes  connect  with  one  another  in  this  manner. 
In  almost  all  instances  the  cavity  opens  into  a  bronchus,  affording 
opportunity  for  the  evacuation  of  the  contents,  which  consist  of  offen- 
sive purulent  secretion  with  degenerated  cells,  elastic  fibers,  detritus, 
tubercle  bacilli,  and  pathogenic  microorganisms.  A  considerable  dif- 
ference is  noted  in  the  character  of  the  walls.  When  the  degenerative 
process  is  rapid,  as  in  acute  pneumonic  phthisis,  the  wall  consists  of  an 
irregular  mass  of  yellowish-gray  ca.seous  tissue.  Sometimes  the  degree 
of  excavation  is  indeed  remarkable,  even  an  entire  hmg  being  broken 
down  into  an  enormous  cavity,  as  illustrated  in  plate  8.  Perforation  of 
pleura,  producing  an  open  or  valvular  pneumothorax,  not  infrequently 
results  from  the  existence  of  cavities  beneath  the  visceral  layer. 

In  the  more  chronic  forms  of  pulmonary  tuberculosis  the  walls  of 
most  cavities  are  somewhat  defined  by  fibrous  tissue  proliferation.  In 
place  of  an  encircling  area  of  tuberculous  pneumonia  undergoing  degen- 
eration, as  in  the  acute  forms  of  phthisis,  there  may  lie  miliary  tubercle 
formation,  associated  with  considerable  fibrous  tissue  hyperplasia.  Pus 
is  produced  from  the  granulation  tissue  constituting  the  inner  surface. 
This  surrounding  fibrous  tissue  is  usually  more  or  less  vascular  or  hemor- 
rhagic, and  is  frequently  spoken  of  as  the  "pyogenic  membrane."  The 
walls  maybe  smooth  or  rough,  and  irregular  from  protruding  remnants 
of  pulmonary  tissue  or  traversed  by  blood-vessels  with  or  without 
aneurysni;il  ililatation.  As  previously  shown,  these  vessels  are  some- 
times uMitciatiMl  following  occlu.sion  of  the  lumen  with  thrombi.  They 
often  pass  directly  through  portions  of  the  cavity,  and  present  varying 
degrees  of  saccular  dilatation  incident  to  the  absence  of  external  support. 
The  cavities  may  exist  in  any  portion  of  the  lung,  although  found  more 
frequently  at  the  apex.  The  increase  of  size  is  slow  in  proportion  to 
the  amount  of  surrounding  connective-tissue  hyperplasia.  When  the 
walls  consist  of  dense  cicatricial  tissue,  the  further  progress  of  the  exca- 
vation is  almost  entirely  checked.  If  the  cavities  are  small  and  the 
surrounding  fibrosis  extensive,  there  is  not  only  an  encapsulation  of  the 
diseased  area,  but  often  a  resulting  obliteration  of  the  cavity  itself.     I 


Section  of  lung  hardened  in  formalin,  showing  the  two  halves  open.  Enormous 

cavity  formation.     Note  connection  between  the  upper  and  lower  cavities.  Note  the 

smooth  inner  surface  of    cavity,  with  almost  entire  absence  of    trabeculse  or  vessels. 
Areas  of  caseous  ])neumonia  in  the  lower  poi'tion  of  the  lung. 


GROSS    APPEARANCES  91 

have  noted  many  times,  after  the  lapse  of  several  years,  a  complete  dis- 
api^earance  of  the  physical  signs  of  pulmonary  cavities  the  existence  of 
which  had  been  previously  establisheti.  In  a  few  cases  the  skiagraph 
has  served  to  demonstrate  the  ai)i>aiciii  uMiteration  of  pulmonary 
cavities  in  individuals  exhibiting  undnuliiiil  cn  idence  of  excavation  upon 
previous  a:-ray  examination.  Tubercle  ba,(-illi  have  been  identified  in 
the  walls  of  pulmonary  cavities  which  are  undergoing  rapid  cheesy 
degeneration  and  necrosis.  They  are,  as  a  rule,  less  virulent  in  old 
cheesy  foci,  and  may  be  absent  or  at  least  infrequent  in  cavities  whose 
walls  consist  of  contracting  cicatricial  tissue. 

The  data  secured  from  clinical  ol^ervation  lead  to  the  conclusion 
that  cavities  are  exceedingly  likely  to  develop  in  the  upper  portion  of 
the  lung  from  the  clavicle  to  the  third  rib,  anil  in  the  back  in  the  inter- 
scapular space. 

CHRONIC  FIBROID  PHTHISIS 

While  in  caseofibroid  phthisis  the  process  of  repair  is  exhibited  to  a 
varying  degree,  in  the  condition  known  as  fibroid  phthisis  the  connective- 
tissue  proliferation  is  particularly  excessive.  In  early  cases  of  chronic 
pulmonary  tuberculosis  the  small  tuberculous  areas  are  surrounded  by 
connective  tissue.  This  fibrous  hyperplasia  is  present  to  some  extent 
in  the  peripheral  portion  of  each  elementary  tubercle,  and  also  con- 
stitutes an  encircling  wall  involving  the  entire  tuberculous  mass.  The 
diseased  tissue  may  thus  become  circumscribed  entirely  by  the  protec- 
tive barrier,  dense  puckering  of  cicatricial  tissue  resulting  from  advanc- 
ing fibrosis  and  contraction.  In  other  cases  calcareous  metamorphosis 
of  the  cheesy  material  takes  place  within  the  encapsulated  area.  Pulmo- 
nary concretions  are  formed  in  this  way,  and  are  sometimes  expectorated 
in  the  act  of  coughing.  It  occasionally  happens  in  cases  of  incomplete 
calcareous  change  that  the  capsule  is  perforated  e\'en  after  many  years 
of  apparent  arrest  of  the  tuliorculous  process,  thus  permitting  fresh 
areas  of  infection.  In  fibrciid  ]ihthisis  the  cdniiective-tissue  ])rolif- 
eration  extends  from  minute  foci  of  infection  which  are  sufficiently 
confluent  to  form  masses  of  conglomerate  tubercles,  and  are  not  associ- 
ated with  diffu.se  infiltrative  change  or  pneumonic  consolidation.  Bands 
of  connective  tissue  proceed  from  the  great  vessels  and  bronchi  into  the 
pulmonary  structures,  which  eventually  become  interwoven  by  a  dense 
fibrous  organization.  The  tissues  thus  permeated  by  fibrous  hyper- 
plasia become  the  seat  of  excessive  contraction  change,  the  sclerotic 
condition  often  invading  all  portions  of  the  lung.  It  is  not  infrequent 
that  extensive  areas  of  connective-tissue  proliferation  are  present  in 
certain  portions  of  a  diseased  lung,  while  a  more  recent  active  tuber- 
culous infection  is  progres.sing  in  other  parts.  Although  in  many 
cases  of  fibroid  phthisis  isolated  areas  of  tubercle  deposit  alone  are 
encapsulated  and  interspersed  by  the  connective-tissue  hyperplasia, 
the  reparative  process  sometimes  becomes  so  overdeveloped  as  to 
produce  extensive  pleuritic  adhesions  and  contractions,  diminishing 
materially  the  respiratory  capacity.  Pleuritic  adhesions  are,  of  course, 
frequent  in  practically  all  varieties  of  pulmonary  tuberculosis,  and 
result  from  the  presence  of  a  fibrinous  inflammatory  exudate  upon 
the  surface.  The  pleura  may  be  thickened  enormously,  with  miliary 
tubercles  sometimes  found  upon  the  surface.  The  pleural  cavity  may 
become  the  seat  of  a  suppurative  process  from  the  entrance  of  tubercle 


92  ETIOLOGY    AND    PATHOLOGIC    ANATOMY 

bacilli  and  the  microorganisms  of  mixed  infection  which  proceed  from 
contiguous  areas  of  disease.  In  case  of  perforation  of  the  pleura  with 
entrance  of  air  to  the  pleural  cavity  the  resulting  pulmonary  collapse 
is  complete  or  partial,  according  to  the  presence  or  absence  of  firm 
pleuritic  adhesions. 

SITE  OF  PRIMARY  INVOLVEMENT 

The  initial  point  of  election  in  pulmonary  tuberculosis  has  been  the 
subject  of  con.siderable  clinical  and  pathologic  study  in  recent  years.  It 
was  formerly  believed  that  the  infection  orginated  at  the  very  apex  of  the 
lung,  and  proceeded  downward  as  a  result  of  the  inhalation  of  the  tuber- 
culous material  to  other  portions  of  the  respiratory  tract.  Special  oppor- 
tunities for  the  spread  of  the  infection  were  believed  to  be  afforded  by 
the  convej-ance  of  the  bacilli  to  previously  uninfected  areas  through 
the  inspiratory  efforts  incident  to  coughing.  Localized  catarrhal  con- 
ditions of  the  finer  bronchi  were  thought  to  be  followed  by  tuberculous 
ulceration  and  by  the  penetration  of  bacilli  into  the  peribronchial  tissues. 
The  predilection  of  the  tubercle  bacillus  for  the  apical  region,  while 
universally  recognized,  was  definitely  attributed  to  such  general  causes 
as  a  weakened  resistance  of  the  tissues  at  this  location,  stagnation  of  the 
circulation,  cUminished  respiratory  excursion,  retention  of  bronchial  secre- 
tions, and  the  efTects  of  prolonged  maintenance  of  stooping  postures 
incident  to  certain  vocations.  For  a  long  time  the  opinion  was  enter- 
tained that  the  infection  was  more  likely  to  involve  the  left  apex  than 
the  right,  on  account  of  a  cUfference  in  the  angles  of  the  primary  bronchi 
with  the  trachea,  .\pical  involvement,  however,  was  not  frequent 
in  children  in  whom  other  portions  of  the  lungs  were  often  primarily 
affected.  The  initial  tuberculous  process  in  cattle  was  found  at  the 
tip  of  the  caudal  lobe.  It  has  not  been  made  clear  that  the  circulation 
at  the  apex  is  materially  enfeebled,  and  it  is  difficult  to  reconcile  the 
theory  of  a  localized  region  of  lessened  resistance  with  the  clinical  fact 
that  tuberculous  infection  of  the  apex  is  frequent!}-  susceptible  to  com- 
plete arrest.  0.sler  reports,  out  of  427  cases,  the  right  apex  was  found 
involved  in  172,  the  left  in  1.30,  and  both  in  11.  Out  of  2070  cases  of  my 
own  whose  records  have  been  preserved,  the  clinical  evidence  pointed  to 
priority  of  infection  at  the  right  apex  in  978  cases,  and  at  the  left  in  783. 
At  the  time  of  first  examination  lesions  were  recognized  in  both  apices 
in  1096  cases,  the  tuberculous  process  being  about  equally  advanced 
upon  the  two  sides  in  117.  .^ufrecht's  theory,  which  has  been  sub- 
stantiated by  the  experiments  of  Calmette.  Guerin,  and  others,  was 
to  the  effect  that  the  bacilli  gained  entrance  to  the  great  veins  and 
obtained  a  lodging-place  in  the  terminals  of  the  pulmonari'  arteries 
at  the  apex.  This  effectually  disposes  of  the  common  error  that  the 
site  of  the  initial  lesion  is  indicative  of  the  point  of  entrance  of  the 
bacillus  into  the  body.  It  may  be  assumed  that  tubercle  bacilli  are 
inhaled  to  an  equal  degree  into  all  portions  of  the  respiratory  tract. 
Upon  the  theory,  therefore,  of  inhalation  tuberculosis,  no  reasonable 
or  .satisfying  explanation  has  been  advanced  relative  to  the  frequency 
of  apical  involvement  resulting  from  certain  precUsposing  mechanical 
conclitions  at  this  point.  Upon  the  basis,  however,  of  localized  infec- 
tion through  the  blood-vessels,  the  constancy  of  apical  infection  is 
possible  of  explanation  through  the  influence  of  the  lymph-streams. 


PLATE    t). 


Section  of  lung  hardened  in  formalin,  showinj^  extensive  areas  of  anthr 
not  only  the  involvement  at  root,  but  also  the  disseminated  areas  at  the 
fibrous  puckering  at  apex. 


I 


GROSS    APPEARANCES  \)6 

Cobb  has  called  attention  to  the  vis  h  fronte,  or  suction  pull,  which 
countercurrent  arises  from  the  great  veins  and  lymi)hutic  vessels  in 
the  angles  of  the  neck,  producing  an  area  of  lymphatic  stasis  in  the 
apices  of  the  lung.  It  is  known  that  the  primary  lesion  of  tuberculosis 
is  not  at  the  extreme  apex,  but  at  a  point  somewhat  below,  varying, 
accorchng  to  the  reports  of  several  investigators,  from  one-half  an  inch 
to  one  and  one-half  inches  below  the  summit  of  the  lung,  and  usually 
somewhat  nearer  to  the  posterior  surface.  Fowler  believes  that  the 
location  of  the  initial  lesion  is  also  nearer  the  external  border.  The 
primary  focus  is  reported  by  him  to  correspond  to  a  point  a  little  below 
the  middle  portion  of  the  clavicle,  and  to  extend  along  the  anterior 
border  of  the  upper  lobe.  Several  authors  corroborate  this  initial  area 
of  infection  by  the  detection  of  early  physical  signs  at  the  middle  of  the 
clavicle,  or  just  below  it,  ami  sometimes  in  the  supraspinous  fossa. 
Another  point  of  early  infer!  icm.  a,;  imlicated  by  Fowler,  is  found  below 
the  outer  third  of  the  clavicle^  with  downward  extension  along  the 
outer  portion  of  the  upper  lobe.  Involvement  of  the  lower  lobe  is 
described  as  taking  place  slightly  below  its  apex  in  the  posterior  portion, 
on  a  line  with  the  fifth  dorsal  spine.  Some  observers  have  gone  so  far 
as  to  state  that  the  apex  of  the  lower  lobe  is  affected  in  the  great  major- 
ity of  cases  in  which  the  physical  signs  of  tuberculosis  were  recognized 
at  the  apex  of  the  iipiJcr.  They  assert  that  the  tuberculous  process 
does  not  involve  the  uppnsite  upjjer  lobe  until  the  apex  of  the  lower 
lobe  of  the  lung  first  diseased  has  liecnme  the  seat  of  tuberculous  le- 
sions. While  infeelimi  readily  extends  upon  the  right  side  from  the 
upper  to  the  iniddle  julx's,  and  upon  the  left  from  the  upper  to  the 
lower,  it  is  (pieslionable  if,  as  claimed,  the  process  has  invariably  in- 
vaded the  ujiper  poitidH  of  the  lower  lolie  before  the  disease  is  recog- 
nized in  the  other  apex.  From  a  purely  clinical  stand]i<iiiit,  it  m.-iy  lie 
asserted  that  the  physical  signs  are  sometimes  recognized  |i(jsieriiirly 
before  the  anterior  apex  is  involved.  The  initial  physical  evidences  are 
observed  very  much  more  frequently  above  the  e];i\i(le  than  below. 
They  may  be  detected  extending  downward  from  fhe  claxii'le  along  the 
anterior  and  internal  border  of  the  lung,  in  the  absence  of  physical  signs 
in  the  middle  or  outer  portion.  The  outer  portion  of  the  upper  lobe 
below  the  clavicle  is  rarely  found  to  l)e  the  seat  of  tuberculous  invasion 
without  the  existence  of  physical  signs  along  the  internal  or  anterior 
border.  The  upper  portion  of  the  lower  lobe  is  often  invaded  simul- 
taneously with  the  recognition  of  the  disease  in  the  apex  of  the  upper 
lobe.  Ill  numerous  instances  I  have  been  able  to  detect  incipient 
lesions  at  this  point  without  phy.sical  signs  at  the  very  apex,  either 
front  or  back.  Upon  the  other  hand,  it  has  not  been  my  experience 
clinically  that  the  upper  portion  of  the  lower  lobe  is  invariably  affected 
before  the  tuberculous  process  extends  to  the  opposite  side. 


PART    11 

SYMPTOAIATOLOGY  AND   COURSE,  VARIETIES  AND 
TERMINATION 

SECTION    I 
Symptomatology 


INTRODUCTION 

A  STRIKING  characteristic  of  the  general  manifestations  of  pulmonary 
tuberculosis  is  the  lack  of  uniformity  of  clinical  features.  Physicians 
who  are  at  all  familiar  with  the  symptomatology  of  consumption  will 
tmite  in  denying  the  existence  of  a  sole  conventional  type  of  the  disease. 
In  no  other  department  of  mechcine  is  the  observer  privileged  to  witness 
a  wider  diversity  of  clinical  phenomena,  or  required  to  exercise  greater 
powers  of  discrimination  and  judgment  in  estimating  the  import  at- 
tached to  various  symptoms.  There  are  few  features  truly  typifying 
the  disease  which  may  not  occur  in  other  pulmonary  affections.  No 
single  sj^mptom  is  invariably  e.xhibited,  and  each  case  must  be  adjudged 
strictly  in  accordance  with  its  own  intrinsic  merits.  Certain  subjective 
symptoms  may  definitely  characterize  some  cases  of  consumption  and 
yet  be  entirely  al)scnt  in  others.  A  few  manifestations  may  be  pos- 
sessed of  sircat  fUnical  import  or  of  comparatively  slight  significance, 
according  to  the  widely  differing  associated  conditions.  Furthermore, 
the  same  rational  signs  displayed  by  a  single  individual  at  different  times 
during  the  course  of  an  active  tuberculous  infection  may  constitute 
clinical  daia  of  ";/•/'/»/ degreesof  importance.  The  ear/v  manifestations 
of  pulmon,ir\  ml  ni  i  ulosis.  although  often  vague  and  ill  defined,  are  of 
great  essential  iiiieiest.  In  no  way  is  the  diverse  symptomatology 
more  definitely  illustrated  than  in  the  manner  of  onset  of  the  disease 
in  different  indivitluals.  It  is  possible,  within  somewhat  flexible  limits, 
to  designate  certain  so-called  types  of  onset  to  which  most  cases  of 
tuberculosis  may  be  said  to  conform. 


CHAPTER  XVI 

METHOD  OF  ONSET 

The  manner  of  invasion  may  be  regarded  as  anite  or  non-acute. 
The  acute  onset  of  tuberculosis  may  occur  in  the  form  of — (1)  Acute 
pneumonic  phthisis:  (2)  acute  bronchopneumonic  phthisis;  (3)  acute 
miliary    tuberculosis    of   the    pneumonic    type:    (4)  initial    pulmonary 


METHOD   OF    ONSET  95 

hemorrhage;  (5)  acute  pleurisy;  (6)  acute  septic  manifestations;  (7) 
acute  bronchitis;  (8)  hi  grippe  or  influenza. 

Acute  Pneumonic  Phthisis. — The  early  manifestations  of  acute 
pneumonic  phthisis  are  essentially  the  symptoms  of  ordinary  croupous 
pneumonia.  Following  an  initial  rigor,  there  takes  place  an  abrupt 
rise  of  temperature,  which  remains  elevated  without  pronounced  re- 
missions during  the  first  few  days.  There  is  often  pain  of  a  stabbing 
nature  in  the  side,  due  to  coincident  pleural  involvement.  The  face  is 
flushed,  eyes  bright,  and  expression  anxious.  The  cough  is  frecjuent, 
dry,  distressing,  and  restrained,  the  expectoration  being  scanty  and 
tenacious.  The  sputum  is  occasionally  streaked  or  flecked  with  blood, 
but  is  sometimes  distinctly  hemorrhagic  in  character.  The  pulse  is 
accelerated,  and  the  respiration  rate  markedly  increased.  Headache 
and  other  constitutional  disturbances  are  present.  Digestive  disorders 
are  frequent,  the  stomach  usually  being  non-receptive  to  other  than 
liquid  food,  and  the  bowels  constipated.  The  urine  is  scanty,  of  high 
specific  gravity,  and  containing  often  a  trace  of  albumin.  The 
physical  signs  are  characteristic  of  croupous  pneumonia.  In  short, 
there  is  nothing  in  the  early  clinical  picture  to  direct  the  attention  of 
the  medical  attendant  to  the  possibility  of  a  tuberculous  invasion. 
No  suspicion  is  entertained  as  to  the  true  character  of  the  disease  until 
the  predicted  resolution  fails  to  take  place  in  the  neighborhood  of  the 
tenth  day.  Even  at  this  time  the  condition  is  often  regarded  as  simple 
pneumonia  with  delayed  resolution,  and  not  until  several  days  later  is 
there  a  beginning  realization  on  the  part  of  the  physician  concerning  the 
unfortunate  possibility  of  acute  tuberculous  involvement.  Tubercle 
bacilli,  even  if  looked  for,  are  rarely  found  during  the  first  few  weeks. 
Following  the  initial  symptoms  there  is  noted,  as  a  rule,  an  irregularity 
of  the  temperature,  with  morning  remissions  and  evening  exacerbations. 
The  temperature  is  sometimes  higher  in  the  morning  than  in  the  after- 
noon, representing  the  so-called  inverse  type  of  fever.  There  is  a 
tendency  toward  sweating,  the  surface  of  the  body  often  being  drenched 
with  perspiration  after  an  abrupt  decline  of  the  fever.  The  loss  of 
flesh  and  strength  is  rapid  and  relentless.  The  expectoration  gradually 
becomes  more  profuse  and  assumes  a  purulent  character.  Areas  of 
softening  are  detected  in  the  midst  of  the  consolidated  lung,  and  cavity 
formation  speedily  supervenes.  At  this  time,  if  not  before,  bacilli  and 
elastic  fibers  are  recognized  in  the  sputum.  The  condition  may  become 
progressively  worse  and  the  patient  die  within  a  few  weeks,  or  the  severe 
symptoms  may  abate  to  some  extent  and  the  case  resolve  itself  appar- 
ently into  ordinary  chronic  phthisis.  Cases  of  acute  pneumonic  tuber- 
culosis, as  well  as  those  of  acute  bnnK  lidixicunionic  phthisis,  are 
frequently  designated  as  "phthisis  floridu"  or  "galloping  consumption." 
Technically,  it  would  seem  better  to  confine  these  appellations  to  cases 
of  acute  ulcerati\'e  i)litliisis  of  «on-pneumonic  onset. 

Acute  Bronchopneumonic  Phthisis. — This  method  of  initial 
tuberculous  inva.sion  may  occur  among  adults  or  children.  In  adults 
particularly  the  symptoms  are  those  of  an  ordinary  bronchopneumonia 
developing  either  in  the  midst  of  apparent  health  or  following  physical 
debilitation  from  various  causes.  The  onset  is  usually  somewhat  less 
acute  than  in  the  pneumonic  form  described  above,  the  ri.se  of  tem- 
perature being  not  so  sudden  or  extreme.  There  may  be  premoni- 
tory chill,  with  pain  in  the  side,  but  these  symptoms  are  often  ab.sent. 


96      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

There  are  early  cough  and  expectoration,  with  moderate  constitutional 
disturbance.  Dyspnea,  headache,  acceleration  of  pulse,  and  general 
prostration  in  the  initial  stages  are  rarely  as  pronounced  as  in  the 
preceding  form.  The  patient  is  compelled  to  go  to  bed,  however,  in 
a  few  days,  if  not  at  once.  Examination  of  the  chest  cUscloses  areas 
of  defective  resonance,  with  characteristic  changes  in  the  pitch,  quality, 
intensity,  and  rhj-thm  of  the  respiratoiy  sounds.  These  scattered 
patches  of  consolidation  may  be  separated  by  normal  lung  tissue,  and 
recognition  of  the  phj-sical  condition  may  thus  be  rendered  exceedingly 
obscure.  The  .signs  are  usually  bilateral,  although  occasionally  confined 
to  one  side.  Numerous  bubbling  rales  are  recognized  throughout  the 
affected  regions,  and  the  conchtion  is  regarded  merely  as  one  of  simple 
bronchopneumonia.  The  persistence  of  the  subjective  symptoms  and 
physical  signs  finally  sugge.sts  the  possibility  of  tuberculosis,  the  con- 
firmation of  which  is  secured  through  detection  of  bacilli  in  the  expec- 
toration. It  is  not  unusual  for  the  patient  to  lapse  into  a  state  resem- 
bling that  of  typhoid  fever,  with  delirium,  intense  headache,  dry  tongue, 
and  eventually  complete  coma.  A  rapid  extension  of  the  tuberculous 
process  takes  place,  the  areas  of  consolidation  merging  into  one  another 
until  the  larger  portion  of  one  or  both  lungs  may  exhibit  massive 
tuberculous  lesions.  Death  may  take  place  in  from  three  to  six  weeks, 
or,  as  in  acute  pneumonic  phthisis,  there  may  result  such  a  stay  of  acute 
manifestations  as  to  justify  a  clinical  assignment  of  the  case  to  the 
class  of  chronic  tuberculo.sis.  It  should  be  borne  in  mind  that  death 
occurring  from  acute  bronchopneumonia  incident  to  hemorrhage  among 
phthisical  patients  is  the  result  of  a  non-tuberculous,  septic,  or  aspira- 
tion pneumonia,  to  which  detailed  attention  will  he  given  subsequently. 

Tuberculous  bronchopneumonia  in  children  is  often  more  acute 
than  in  adults.  It  is  most  frequent  as  a  complication  or  sequel  of 
measles  and  whooping-cough.  It  may  occur  not  only  during  the  height 
of  the  original  disease,  but  as  well  in  the  midst  of  convalescence.  The 
patient  may  succumb  in  a  very  few  days,  apparently  from  ordinaiy 
bronchopneumonia.  The  children,  however,  sometimes  improve  after 
one  or  two  weeks  of  acute  illness,  and  enter  upon  a  period  of  more 
gradual  decline,  with  progressive  loss  of  flesh  and  strength. 

Acute  Miliary  Tuberculosis  of  the  Pneumonic  Type. — This,  like 
the  preceding,  may  develop  in  adults  or  children.  The  condition  is  in 
reality  a  general  systemic  involvement,  with  predominating  symptoms 
in  the  huigs.  In  children  the  mournful  affection  may  follow  measles 
or  whooping-cough,  with  symptoms  not  veiy  dissimilar  from  those  of 
acute  bronchopneumonic  tuberculosis.  If  the  child  survives  very  many 
days,  which  is  seldom  the  case,  meningeal  symptoms  are  almost  sure 
to  supervene.  In  adults  the  conchtion  may  develop  in  those  who 
already  exhibit  manifest  evidences  of  tubercle  deposit,  and  in  many 
instances  among  individuals  who  unconsciously  harbor  latent  foci  of 
infection.  The  cough  is  variable,  and  the  expectoration,  if  any,  is  verj' 
scant}'.  The  striking  sj-mptomatic  features  are  the  dyspnea  and 
cyanosis,  both  of  which  are  quite  disproportionate  to  the  physical  signs, 
which  are  those  of  a  diffused  bronchiolitis.  Numerous  very  fine  moist 
r^les  are  heard  throughout  both  sides  of  the  chest.  The.se  may  be 
unrecognized  upon  easy  breathing,  but  clearly  appreciated  following  a 
cough.  Frequently  there  are  no  other  auscultatory  signs,  and  upon 
percussion   no  evidences  of   consolidation.     There  is  marked  loss  of 


METHOD    OF    ONSET  97 

flesh  and  strength,  which  is  attended  by  increasing  dyspnea  and 
cyanosis,  with  or  without  especial  elevation  of  temperature.  The 
pulse  almost  invariably  is  rapid  and  of  poor  quality.  In  some  cases  the 
spleen  is  found  to  be  enlarged.  The  duration  is  usually  short,  meningeal 
tuberculosis  often  developing  in  case  the  disease  is  at  all  prolonged. 
Acute  general  miliary  tuberculosis  will  be  considered  in  a  separate 
section. 

Initial  Pulmonary  Hemorrhage. — In  a  surprisingly  large  number 
of  cases  hemorrhage  is  the  first  symptom  chstinctly  referable  to  the 
onset  of  pulmonary  tuberculosis.  It  may  occur  in  the  midst  of  apparent 
health,  the  patient  being  well  nourished,  without  cough,  expectoration, 
or  fever,  and  entertaining  not  the  least  notion  of  approaching  danger. 
In  many  of  these  cases  thorough  examination  of  the  chest  fails  to 
disclose  the  slightest  pulmonary  lesion,  although  in  others  physical 
evidence  of  incipient  infection  may  be  recognized.  The  initial  hemor- 
rhage without  regard  to  the  physical  signs  may  be  small,  moderate, 
or  copious.  The  expectoration  of  IJoocl-stiiined  mucus,  which  is  pro- 
duced by  a  congestion  of  the  bronchial  mucosa,  has  but  slight  signifi- 
cance in  this  connection. 

Formerly  it  was  believed  that  early  hemorrhages  were  not  so  much 
the  result  as  the  cause  of  tuberculosis,  but  this  theory  is  now  known  to  be 
utterly  untenable.  Tubercle  bacilli  have  been  found  in  the  fresh  blood 
of  the  initial  hemorrhages.  It  has  been  taught  that  hemorrhages  of 
any  considerable  size  can  result  only  from  the  rupture  of  an  artery 
traversing  a  pulmonary  cavity,  the  wall  of  the  blood-vessel  being  with- 
out its  normal  connective-tissue  support  and  finally  yielding  to  intra- 
arterial pressure.  If  this  were  the  only  cause  of  moderate  or  large-sized 
hemorrhages,  it  would  be  hard  to  explain  their  very  frequent  occurrence 
among  patients  exhibiting  no  symptoms  or  physical  signs  of  tuberculous 
infection.  It  seems  reasonable  to  assume  that  many  of  the  early 
hemorrhages  are  produced  by  a  beginning  tubercle  deposit  involving 
the  wall  of  the  artery  itself,  before  any  considerable  destructive  change 
has  taken  place  in  the  pulmonary  tissue.  The  wall  of  the  blood-vessel 
is  weakened  as  a  result  of  caseation,  and  perforation  takes  place  before 
the  appearance  of  sul^jective  symptoms  or  i)li}>i(al  simis.  Another 
cause,  though  perhaps  less  frequent,  may  be  assuiiicil  to  be  the  oblitera- 
tion of  the  terminal  branches  of  the  pulmonary  artery  through  early 
tuberculous  infection,  increasing  the  intra-arterial  pressure  just  behind 
the  point  of  obstruction.  Hemorrhages  from  these  causes  are  likely 
to  be  comparatively  small  or  moderate  in  size.  I  have  known,  however, 
many  serious  and  copious  hemorrhages  to  take  place  as  the  very  first 
symptom  of  pulmonary  tuberculosis. 

Hemorrhages  which  result  from  genuine  cavity  formation  and 
pulmonary  aneurysms  are  especially  severe  and  often  immediately 
fatal,  but  these  rarely  appear  as  an  initial  symptom. 

An  interesting  consideration  relates  to  the  time  of  the  development 
of  other  manifestations  following  the  preliminary  hemorrhage.  In 
many  cases,  particularly  if  the  bleeding  is  severe,  a  persisting  cough  at 
once  makes  its  appearance,  together  with  varying  elevations  of  tem- 
perature, expectoration,  loss  of  flesh  and  strength,  and  the  physical 
evidences  of  tuberculous  disease.  In  these  cases,  while  the  hemorrhage 
is  the  immediate  precursor  of  rational  symptoms  and  physical  signs,  it  is 
by  no  means  the  cause  of  the  infection.  In  many  cases  the  early  hem- 
7 


yS       SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

orrhage  is  followed  by  an  apparent  complete  recovery,  several  months 
or  even  years  elapsing  before  the  recurrence  of  pulmonary  symptoms. 
In  nearlj'  all  cases,  however,  the  unmistakable  manifestations  of 
tuberculosis  are  delayed  only  for  the  time  being. 

In  1901,  in  an  analj'sis  of  900  private  cases  of  pulmonary  tuberculosis, 
I  found  that  175  patients,  or  about  20  per  cent.,  gave  the  history  of  a 
sudden  hemorrhage  as  the  first  symptom  of  their  intrathoracic  disease. 
Out  of  a  recent  analysis  of  2070  cases  of  pulmonary  tuberculosis  347,  or 
about  17  per  cent.,  were  found  to  have  had  a  pulmonary  hemorrhage  as 
the  initial  symptom  of  the  tuberculous  infection.  In  addition,  25  were 
found  to  present  a  history  of  hemorrhage  one  year  before  the  clinical 
recognition  of  the  pulmonary  affection,  13  two  years  before,  and  32  over 
two  years. 

The  subject  of  pulmonary  hemorrhage  will  be  discussed  later  in 
more  detail. 

Acute  Pleurisy. — It  has  been  known  for  many  years  that  a  large 
majority  of  the  so-called  idiopathic  pleurisies  are  tuberculous  in  char- 
acter. While  manj^  pleurisies,  either  with  or  without  effusion,  end  in 
apparent  recovery,  some  are  followed  after  the  lapse  of  months  or  years 
by  the  development  of  pulmonary  tubercidosis.  It  is  not  very  uncom- 
mon to  observe  patients  whose  cough,  expectoration,  fever,  and  phj^sical 
signs  immechately  follow  the  acute  pleural  invasion  or  so  shortly  there- 
after as  to  justify  their  classification  as  cases  of  acute  onset  character- 
ized by  an  initial  pleurisy. 

Out  of  2070  recorded  cases  of  pulmonary  tuberculosis,  I  have  found 
126  presenting  the  history  of  an  idiopathic  pleurisy  as  the  first  symptom 
referable  to  the  disease. 

The  presence  of  tubercle  bacilli  in  the  pleural  effusion  is  a  matter 
of  comparatively  little  clinical  moment.  I  have  demonstrated  their 
presence  in  some  cases,  while  in  others  the  bacilli  have  appeared  sub- 
sequently in  the  sputum  despite  negative  examinations  of  the  exudate. 
Involvement  of  the  pleura  will  be  discussed  at  some  length  under 
Complications. 

Acute  Septic  Disturbances. — A  number  of  patients  present  the 
history  of  an  initial  chill  with  a  sharp  rise  of  temperature  as  the  first 
manifestations  of  tuberculous  infection.  The  constitutional  distur- 
bances may  later  become  profound,  even  in  the  absence  of  any  immediate 
suggestion  of  pulmonary  disease.  The  chills  may  be  of  daily  occurrence 
and  of  variable  intensity,  ranging  from  a  succession  of  severe  rigors 
to  slight  chilly  sensations  along  the  spine.  The  temperature  is  often 
subnormal  in  the  morning,  ascending  rapicUy  in  the  afternoon,  falling 
abruptly  in  the  evening  or  at  night,  and  followed  by  more  or  less 
perspiration.  There  are  headache,  pain  in  the  limbs,  loss  of  appetite 
with  digestive  disorders,  rapid  emaciation,  and  marked  prostration. 
(See  chapter  devoted  to  Mixed  Infection,  p.  541.)  Such  cases  occasion- 
ally are  regarded  as  malarial  in  origin,  and  sometimes  are  thought  to  l)e 
of  a  typhoid  nature.  Cough,  expectoration,  and  all  other  symptoms 
of  pulmonary  infection  may  be  absent  at  first,  but  after  a  short  time 
searchintr  ox.iiniii.itinn  will  disclose  the  physical  signs.  The  spleen 
isusuall\-  cnlii'^cil.  and  a  innilcratc  leukocj^tosis  is  present.  The  failure 
of  the  W'idal  rcartidii  and  the  aiisence  of  the  malarial  Plasmodium  in 
the  blood  are  sufficient  to  call  attention  to  the  possibility  of  tuberculous 
infection  even  before  the  recognition  of  physical  signs.     I  have  had 


METHOD    OF    ONSET  99 

occasion  to  observe  a  very  considerable  number  of  patients  presenting 
the  histories  of  supposed  malaria  or  typhoid  fever,  for  which  they  had 
been  treated  for  weeks  or  months.  It  is  of  interest  to  note,  however, 
that  many  such  invalids  later  exhibit  the  clinical  manifestations  of  a 
general  miliary  tuberculosis,  the  early  symptoms  corresponding  to 
the  so-called  typhoid  type,  with  pulmonary  or  meningeal  symptoms 
subsequently  <level()])in,2,-. 

The  Bronchitic  Onset. — With  some  patients  the  contraction  of  a 
severe  cold  is  stated  to  be  the  first  symptom  of  pulmonary  tuberculosis. 
Many  of  these  present  the  history  of  recurring  bronchial  attacks  which 
gradually  became  more  frequent  and  of  increased  sovciity,  iiniil  the 
cough  was  persistent  and  other  sjnnptoms  of  tubcrculnsis  wcic  well 
defined.  Many  piilnidnny  invalids  assert  that  their  early  symptoms 
were  traceable  (lii-ccil\-  td  a  single  severe  cold  with  pain  in  the  chest, 
cough,  and  expei'toiatiou,  which  thej^  since  had  been  unable  to  over- 
come. Phthisical  patients  displaying  a  distinct  bronchitic  unset  .ilmost 
invariably  exhibit  a  striking  degree  of  bronchial  initaliuii  tlnoimliout 
the  subsequent  course  of  the  disease,  the  cough  beini^  dist  icssing, 
paroxysmal,  and  entirely  out  of  proportion  to  the  extent  and  activity 
of  the  tuberculous  process. 

La  Grippe  or  Influenza. — For  six  or  seven  years  following  1890 
la  grippe  was  a  most  potent  factor  in  the  causation  of  pulmonary 
tuberculosis.  During  these  years  the  frequency  with  which  patients 
ascribed  their  early  symptoms  of  tuberculosis  to  an  acute  attack  of 
la  grippe  was  quite  remarkable.  In  1897,  out  of  200  cases  of  tubercu- 
losis then  under  observation,  19  per  cent,  traced  the  origin  of  their 
trouble  to  an  attack  of  influenza  which  was  frequently  of  but  a  few  days' 
duration.  This  proportion  has  diminished  perceptibly  in  succeeding 
years. 

An  interesting  feature  of  the  development  of  consumption  following 
la  grippe  has  been  the  benign  character  of  the  original  influenza  infec- 
tion. Another  extraordinary  phase  of  the  la  grippe  influence  is  the 
fact  that  in  a  large  number  of  cases  there  was  no  cough  or  bronchial 
disturbance  attending  the  e;  r]\-  inlluenza.  Pulmonary  tuberculosis 
has  often  developed  shortly  .■  lier  ilie  onset  of  the  cerebral  or  tonsillar 
forms  of  la  grippe,  as  well  as  follow mij  the  bronchial  type.  This  sug- 
gests the  thought  that  the  es.sential  influence  of  la  grippe  as  an  etio- 
logic  factor  consists  of  the  sudden  and  extreme  lowering  of  individual 
re.sistance  affording  opportunity  for  rapidly  advancing  tuberculous 
infection. 

The  non-acute  onset  of  tuberculosis  may  develop  as  a  latent  unsus- 
pected infection,  as  the  anemic  variety,  and  the  dyspeptic  type.  It 
also  may  appear  with  laryngeal  .symptoms,  following  tuberculous 
cervical  glands  and  remotely  following  pleurisy,  pneumonia,  typhoid 
fever,  measles,  or  other  infectious  diseases. 

As  a  Latent  Unsuspected  Infection. — Patients  occasionally  state 
that  the  first  intimation  of  existing  tuberculous  involvement  was  the 
medical  report  when  presenting  themselves  for  life-insurance  examina- 
tions, or  seeking  coiuisel  on  account  of  vague  general  disorder.  These 
people  often  deny  the  existence  of  cough  or  expectoration,  but  some- 
times admit  a  slight  clearing  of  the  throat,  especially  in  the  morning. 
Close  questioning  may  elicit  the  admission  of  a  dry,  hacking  cough  which 


100      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

has  been  so  slight  as  almost  to  escape  attention.  There  is,  as  a  rule, 
but  little  loss  of  weight  or  strength.  Fever  has  remained  unsuspected, 
but  the  inteOigent  and  frequent  use  of  the  thermometer  will  show  in 
most  instances  either  a  slight  afteniunii  elevation  of  temperature  or  at 
least  an  average  for  the  day  .somewhat  alHi\c  normal.  As  time  elapses 
these  patients  complain  of  tiring  more  euiily  tlian  formerl}-.  A  beginning 
shortness  of  breath  is  noticed  upon  exertion,  the  cheek  flushes,  the  eye 
becomes  bright,  and  actual  cough  with  expectoration  calls  attention  to 
an  infection  hitherto  latent. 

The  Anemic  Onset. — Like  the  precechng.  the  anemic  type  of  begin- 
ning tuberculosis  is  often  devoid  of  symptoms  suggestive  of  pulmonary 
chsease.  The  onset  is  es.sentially  slow  and  insidious.  The  early  symp- 
toms are  of  a  general  chai-acter,  and  are  usuaUy  ascribed  to  other  causes 
than  an  intrathoracic  affection.  The  patient  is  noticed  to  be  "running 
down,"  and  a  gradual  but  progressive  loss  of  weight  is  apparent. 
Pallor  is  a  more  or  less  striking  feature,  together  with  shortness  of 
breath  and  dizziness.  At  best  there  is  a  tardy  and  incomplete 
appreciation  on  the  part  of  the  patient,  friends,  and  mecUcal  adviser 
of  the  gravity  of  the  situation.  This  method  of  development  is 
thametrically  opposed  to  the  bronchitic  type  of  onset  in  that  the 
tuberculous  process  in  the  lung  is  greatly  disproportionate  to  the  bron- 
chial chsturbance.  Cough  is  a  comparatively  unimportant  symptom, 
and  appears  as  a  conspicuous  feature  only  after  extensive  pathologic 
change  has  taken  place.  Even  when  the  di-sease  has  advanced  con- 
siderably the  evidence  of  bronchial  irritation  ma}-  remain  quite  imper- 
ceptible. Extensive  destructive  change  in  the  lung  usually  takes 
place  before  a  recognition  of  the  real  nature  of  the  disease.  Because 
of  its  insidious  onset  and  the  unconscious  adaptation  of  the  patient 
to  the  condition,  much  valuable  time  is  lost  before  there  is  attained  a 
full  realization  of  its  importance. 

The  Dyspeptic  Type. — Patients  sometimes  ascribe  the  beginning 
of  their  disease  to  severe  tlyspeptic  disorders.  There  are  experienced 
loss  of  appetite,  vomiting,  anorexia,  and  gastralgia  with  acid  eructations. 
Failure  to  ingest  a  proper  amount  of  nourishment  is  attended  by 
picturesque  disturbances  of  a  psj'choneurotic  nature.  With  insufficient 
food  and  profound  depression  of  spirits  there  ensue  progressive  emacia- 
tion, diminished  resistance,  and  a  gradual  development  of  tuberculous 
infection.  Such  patients  are  tremendously  handicapped  in  their  effort 
to  secure  subsequent  arrest  because  of  the  symptoms  commonly  referred 
to  the  stomach,  yet  often  of  unquestionable  psychoneurotic  origin. 
In  the  same  way  preconceived  notions  as  to  inability  to  take  certain 
varieties  of  food  greatly  interfere  with  the  ultimate  chances  of  sucee.ss. 
This  subject  will  be  considered  more  fully  in  succeeding  pages. 

Laryngeal  Manifestations. — In  some  instances  the  first  complaint 
is  that  of  slowl}-  tleveloping  hoarseness.  There  may  be  no  cough  or 
expectoration,  fever,  loss  of  weight  or  strength.  The  hoarseness  is  often 
regarded  as  simplj-  catarrhal,  and  attributed  to  an  insignificant  cold. 
After  persisting  for  a  somewhat  protracted  period,  laryngoscopic  exami- 
nation tliscloses  suggestive  evidence  of  pulmonary  infection.  As  a 
rule,  the  lung  involvement  antedates  the  larrageal  process,  but  is 
sometimes  so  slight  in  its  extent  and  activity  as  to  render  difficult  its 
early  detection,  the  hoarseness  thus  developing  as  the  first  symptom 
of  the  disease.     (See  Tuberculosis  of  the  Laiynx.) 


COUGH    AND    EXPECTORATION  101 

Following  Cervical  Lymphatic  Tuberculosis. — While  pronounced 
tuberculous  imohcnicnt  of  tlie  lyniphutic  .inlands  of  the  neck,  with  or 
without  .su])pui'ati()n,  may  persist  for  many  years,  in  the  absence  of  pul- 
monary infection  such  condition  nevertheless  must  be  regarded  as  a 
distinct  menace  to  the  individual.  That  pulmonary  tuberculosis  may 
develop  eventually  from  this  source,  as  well  as  from  concealed  glandular 
foci  in  other  parts  of  the  body,  is  too  well  known  to  warrant  more  than 
passing  allusion.  As  a  matter  of  clinical  observation,  tuberculosis  of  the 
cervical  lymphatic  glands  not  uncommonly  is  found  to  be  a  preliminary 
manifestation  of  pulmonary  invasion.  In  some  instances  the  scrofulous 
type  of  infection  may  strongly  predominate  in  spite  of  a  developing  pul- 
monary process.  In  such  cases  the  physical  signs  may  be  of  trifling 
importance  in  comparison  with  the  degree  of  cervical  enlargement  and 
characteristic  constitutional  disturbances.  A  pronounced  lymphatic 
involvement  may  produce  but  a  slight  pulmonary  invasion,  but  a  small 
non-suppurative  cervical  gland,  devoid  of  inflammation  and  freely  mov- 
able under  the  skin,  may  serve  as  the  point  of  departure  of  an  extensive 
and  active  pulmonary  infection.  Glandular  tuberculosis  will  be  dis- 
cussed quite  fully  under  Complications. 

Remotely  Following  Pleurisy,  Pneumonia,  Typhoid  Fever, 
Measles,  or  other  Infectious  Disease. — Patients  sometimes  report 
a  condition  of  perfect  health  until  overcome  by  a  severe  attack  of  one 
of  the  acute  infectious  diseases.  Although  convalescence  is  sometimes 
slow  and  unsatisfactory,  they  apparently  recover  in  part  from  the 
primary  disease,  but  fail  to  regain  to  the  full  extent  their  former  strength 
and  endurance.  They  resume  their  usual  occupation,  but  feel  tired 
and  weak,  with  evidently  diminished  powers  of  resistance.  After 
varjdng  periods  the  cough,  expectoration,  loss  of  weight,  and  other 
symptoms  of  tuberculosis  make  their  appearance.  In  such  cases  the 
evidence  of  an  increased  receptivity  of  the  soil  through  the  influence  of 
the  infectious  disease  in  individuals  previously  in  good  health  seems 
too  strong  to  admit  of  reasonable  cloubt.  The  effect  of  pregnancy 
will  be  considered  later. 

It  should  be  borne  in  mind  that  in  very  many  instances  the  peculiar 
type  of  onset  stamps  its  impress  upon  the  subsequent  course  of  the 
disea.se,  and  to  a  marked  extent  influences  prognosis.  This  will  be 
treated  more  fully  in  connection  with  the  Clinical  Course  and  the 


CHAPTER  XVII 
COUGH  AND  EXPECTORATION 

COUGH 

There  is  no  manifestation  of  pulmonary  tuberculosis  more  popularly 
regarded  as  suggestive  of  the  disease  than  cough,  and  yet  none  is  more 
subject  to  variations  in  its  character  and  extent.  There  is  no  definite 
relation  between  this  symptom  and  the  activity  of  the  tuberculous 


102       SYMPTOMATOLOGY    AND    COURSE,    \ARIETIES    AXD    TERMINATION 

process  or  the  nature  of  the  pathologic  change.  Several  times  I 
have  observed  individuals  exhibiting  pronounced  physical  evidences  of 
cavity  formation  and  with  wide  areas  of  tuberculous  disease,  who  at  no 
time  presented  the  history  of  cough  or  expectoration.  More  frequently 
the  reverse  of  this  is  observed,  i.  e.,  that  the  cough  is  out  of  all  pro- 
portion to  the  extent  of  structural  change.  In  reality  the  cough  is 
but  a  reflex  phenomenon  resulting  from  various  degrees  of  irritation 
of  the  bronchial  mucosa,  often  quite  independent  of  the  tubercle  deposit. 
It  is  usually  excited  by  the  presence  of  secretion,  the  most  sensitive 
portions  of  the  respiratory  tract  being  at  the  bifurcation  of  the  trachea 
and  the  interarytenoid  commissure.  The  cough,  as  a  rule,  is  more 
pronounced  upon  awakening  in  the  morning,  by  virtue  of  the  fact  that 
the  secretions  have  been  permitted  to  accumulate  during  the  night, 
and  the  reflexes  have  been  held  comparatively  in  abeyance.  The 
degree  of  irritation  varies  within  wide  limits,  according  to  the  idiosyn- 
crasies of  the  patient.  Sometimes  temperamental  peculiarities  are 
found  to  exert  an  undouljted  influence  upon  the  severity  of  the  cough. 
The  non-excitable  and  phlegmatic  are  inclined  to  cough  but  little,  and 
then  only  to  expel  secretions,  while  people  of  a  distinctly  nervous  type 
frequently  indulge  in  prolonged  and  distressing  expulsive  efforts  which 
are  attended  by  scanty,  if  any,  expectoration.  This  relation,  however, 
as  to  the  individual  temperament  and  the  character  of  the  cough,  does 
not  exist  in  all  cases. 

A  common  conception  regarding  the  cough  is  to  the  effect  that  it  is 
slight  in  the  beginning,  and  that  its  subsequent  frequency  and  severity 
are  commensurate  with  the  further  advance  of  the  disease.  This  is  far 
from  being  the  case.  The  character  and  frequency  of  the  cough  afford 
no  criterion  by  which  to  judge  of  the  clinical  progress.  In  fact,  bron- 
chial irritation  may  be  decidedly  increased  in  spite  of  .subjective  and 
physical  evidences  of  diminished  tuberculous  activity,  and  vice  versft. 
In  other  words,  the  cough  may  get  better  as  the  patient  grows  steadily 
worse,  or  it  may  become  aggravated  notwithstanding  decided  general 
improvement.  It  is  occasionally  true  that  in  dry,  dust\^  climates  the 
bronchial  irritation  is  maintained  in  the  midst  of  a  progressive  arrest 
of  the  infection.  Especial  care  should  be  taken  in  such  cases  to  acquaint 
the  patients  with  a  full  knowledge  of  their  exact  status,  in  order  that  no 
misconceptions  as  to  their  condition  may  be  entertained  as  a  result  of 
a  persisting  or  aggravated  cough.  In  extreme  instances  it  sometimes 
becomes  a  choice  of  the  lesser  of  two  evils,  in  which  event  the  tubercu- 
lous element  in  most  cases  should  take  precedence,  particularly  if  there 
exists  any  remaining  evidence  of  tuberculous  activity.  Altitude 
and  dryness  are  inevitably  associated  with  a  degree  of  variability  in 
temperature,  and  while  this  combination  is  conducive  to  individual 
improvement,  the  bronchial  irritation,  nevertheless,  may  remain 
somewhat  aggravated.  After  the  tuberculous  process  has  become 
arrested  demonstrably,  this  disturbance  may  be  expected  in  many 
cases  to  be  mitigated  by  the  equability  of  the  lowlands,  the  accom- 
panying moisture  then  being  less  likely  to  produce  harmful  effects  upon 
the  underlying  disease.  Bronchial  irritation  is  often  especially  pro- 
nounced in  cases  of  emphysema,  asthma,  and  dry  bronchitis.  Upon 
the  other  hand,  patients  with  moist  bronchitis,  on  going  to  high  dry 
climates,  sometimes  experience  a  remarkable  diminution  in  the  severity 
of  the  bronchial  disturbance  long  before  the  physical  signs  reveal  an 


COUGH    AND    EXPECTORATION  103 

actual  improvement  in  the  tuberculous  lung.  Climatic  influences  will 
be  considered  at  length  in  a  separate  chapter. 

Generally  speaking,  the  cough  may  vary  from  a  slight  clearing  of 
the  throat  to  violent  and  prolonged  paroxysms  of  expulsive  effort. 
Exclusive  of  individual  idiosyncrasies  and  temperamental  influences, 
the  cough  may  be  said  to  partake  more  frequently  of  a  paroxysmal 
nature  in  the  presence  of  pulmonary  cavities,  bronchiectases  or  pneu- 
mothorax, and  severe  coexisting  chronic  bronchitis.  The  paroxysms 
occur  at  intervals  and  are  especially  marked  in  the  morning  and  at 
night.  Change  of  posture  often  exerts  a  striking  influence  in  the 
causation  of  violent  spells  of  coughing.  This  is  observed  not  only 
upon  arising  in  the  morning  and  retiring  for  the  night,  but  also  when 
the  patient  reclines  d\iring  tiie  day,  turns  from  one  side  to  another  in 
bed,  stoops  over,  or  chanucs  t\\r  posilion  to  ;iny  luaikcd  cxlciit.  A 
slight  amount  of  jiIin  >ii-.il  cxcirisc  is  often  pinductiM'  oF  a  similar  result. 
The  paroxysms  are  also  induced  by  going  hxnn  a  warm  r(K)m  into  the 
cooler  outside  air,  or  upon  alternation  of  heat  and  cold  within  doors. 
Severe  paroxysms  often  take  place  after  eating  a  very  hearty  meal,  upon 
exposure  to  a  draft  or  strong  wind,  the  inhalation  of  dust,  indulgence  in 
hearty  laughter,  grief  or  sudden  emotion,  nervous  excitation  oi'  alroholic 
stimulation.  The  paroxysms  may  vary  from  a  few  nioim  nts  to  several 
minutes'  duration,  during  which  time  the  face  becomes  sulfu.scd  with  a 
purplish  lliisli.  tlie  veins  nf  the  heel  iind  ueek  unduly  prominent,  visible 
perspiration  in(liii'e(|  upon  the  liiou,  and  in  Some  cases  involuntary 
micturition,  \oinitiiig  is  a.n  unfortunate  accompaniment  of  the  cough. 
It  is  particularly  likely  to  ensue  by  virtue  of  the  pharyngeal  reflex  if 
the  paroxysms  follow  a  hearty  meal.  This  unfortunate  symptom  often 
interferes  materially  witli  the  chances  for  recovery,  on  account  of  the 
difficulty  imposed  in  maintainin<;  suffiiierit  alimentation.  When  pos- 
sible, the  patient  should  be  comiielled  lo  jiaitake  of  more  I' 1  siiortly 

after  the  cessation  of  vomit inu,  it  is  .seldom  that  a  similar  result 
follows  the  second  meal,  :e  the  luduehial  secretions  are  evacuated  to 
some  extent  in  the  act  of  \'oniitiMi:,  1  have  observed  that  the  majority 
of  patients  who  suffer  from  this  dist icssing  symptom  experience  their 
greatest  difficulty  after  the  evening  iiie;il,  iiaving  been  able  to  retain 
their  morning  and  midday  nouiislnnent  with  comparative  ease.  For 
such  patients,  as  will  be  explained  later,  et)mplete  rest  after  the  ingestion 
of  food  is  essential,  with  sometimes  the  addition  of  cracked  ice  or 
cocainization  of  the  pharynx. 

EXPECTORATION 

Like  the  cough,  the  expectoration  is  a  decidedly  variable  factor  in 
pulmonaiy  tulx'iculo- is.  There  are  presented  striking  differences  in 
quantity,  gross  .'ippeaiance,  manner  of  expulsion,  and  composition. 

The  quantity  may  \":iry  from  half  a  dram  to  over  a  pint  in  twenty- 
four  hours.  It  is  lielieved  (|iiite  -eiiei-ally  that  tiie  quantity  is  slight 
in  early  cases,  and  iiu'icases  in  pnipoilion  tfi  the  onward  progress  of 
the  disease.  In  othei-  wdids,  the  amount  is  supposed  to  correspond 
more  or  less  closel.\-  i<i  the  ,arii\iiy  of  the  involvement  and  the  extent 
of  destructive  change.  While  the  expectoration  frequently  becomes 
more  profu.se  with  increasing  moisture  in  the  chest,  beginning  evidences 
of  softening,  and  the  recognition  of  cavities,  this  is  not  invariably  the 


104       SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

case.  I  often  find  the  expectoration  profuse  when  but  little  moisture 
can  be  recognized  upon  examination,  and,  per  contra,  but  scanty  expec- 
toration in  spite  of  widely  diffused  moist  rales,  in  some  instances 
notwithstanding  the  existence  of  considerable  cavity  formation.  A 
comparatively  copious  expectoration  in  the  absence  of  such  physical 
signs  as  would  suggest  its  occurrence  may  be  explained  by  a  coexisting 
bronchitis  invohing  chiefly  the  larger-sized  tubes  and  producing 
quantities  of  mucopurulent  secretion.  It  is  difficult  to  account  satis- 
factorily for  the  absence  of  cough  and  expectoration  in  indi\iduals 
presenting  upon  examination  the  moist  bubbling  rales  or  cavity  signs 
incident  to  an  active  tuberculous  process.  The  hypothesis  of  a  marked 
diminution  in  the  sensibility  of  the  bronchial  mucosa  is  scarcely  a 
tenable  explanation  in  all  cases,  as  the  expectoration  is  frequently  nil 
despite  repeated  cough  and  the  existence  of  moisture  in  the  bron- 
chioles. 

The  gross  appearance  of  the  sputum  also  is  subject  to  much 
variation  in  tlifferent  individuals,  its  character  being  dependent  largely 
upon  the  extent  and  nature  of  morbid  pulmonary  change.  In  the 
beginning  it  is  often  scanty  and  somewhat  glairy  or  viscid,  consisting 
mostly  of  mucus  with  but  little,  if  any,  pus.  As  the  disease  advances 
tiny  yello^xish  or  greenish-yellow  masses  make  their  appearance.  These 
gradually  increase  in  number  and  size  until  the  sputum  is  essentially 
mucopurulent.  The  yellowish  masses  are  usually  clothed  more  or  less 
with  a  glairy  mucous  coating.  Rarely  is  the  expectoration  distinctly 
purulent,  save  in  cases  complicated  by  an  open  pneumopyothorax, 
in  which  event  the  secretion  is  similar  to  the  pus  of  an  empyema  and. 
sometimes  excessive  in  quantity. 

The  expectoration  from  pulmonary  cavities  is  often  hea\'y,  appar- 
ently homogeneous,  and  of  more  solid  consistenc}^,  sinking  to  the  bottom 
when  deposited  in  water.  This  is  described  as  "  nummular  "  sputum,  and 
although  usually  flattened  to  some  extent,  is  more  or  less  spheric. 
It  is  not  always  indicative  of  pulmonary  cavities,  as  this  variety  of 
sputum  may  be  present  in  cases  of  bronchiectasis. 

The  expectoration  is  sometimes  flecked  with  tiny  specks  of  blood 
or  discolored  by  distinct  hemorrhagic  streaks.  At  other  times  it  is 
reddened  homogeneously  with  bright  blood  or  stained  a  rusty  hue. 
As  a  rule,  the  pre.sence  of  minute  flecks  or  streaks  of  blood  in  the  expec- 
toration is  of  but  little  significance,  as  a  .slight  amount  may  be  deposited 
upon  the  sputum  in  its  progress  through  a  congested  bronchial  tute. 
A  thoroughly  red-stained  expectoration  is  often  regarded  as  suggestive 
of  its  origin  from  an  irritated  pulmonary  cavit3^  Dark  bloody  clots 
contained  in  the  expectoration,  as  a  rule,  are  the  result  of  a  previous 
pulmonary  hemorrhage,  the  blood  having  remained  for  a  considerable 
time  in  the  bronchial  tubes.  A  rusty  expectoration  is  observed  more 
commonly  in  cases  of  tuberculosis  complicated  with  a  beginning  bron- 
chopneumonia. 

The  sputum  in  some  instances  is  light  and  frothy,  showing  an 
abundant  admixture  of  air.  This  form  of  expectoration  occurs  more 
frequently  in  cases  exhibiting  considerable  interstitial  change,  as  in 
fibroid  phthisis,  old  chronic  pleurisies,  and  occasionally  in  asthma. 
It  is  notably  increased  after  administration  of  the  iodids. 

The  expectoration  is  sometimes  described  by  the  patient  as  ha\-ing  a 
somewhat  sweetish  taste  and  of  nauseating  character.     There  is  seldom 


COUGH    AND   EXPECTORATION  105 

any  unpleasant  odor  to  the  sputum  itself,  save  In  the  presence  of  pul- 
monary cavities,  bronchiectasis,  fetid  bronchitis,  or  gangrene. 

Finally,  it  should  be  borne  in  mind  that  it  is  impossible  to  form 
accurate  conclusions  as  to  the  character  of  the  affection  from  the  gross 
appearance  of  the  expectoration,  as  the  sputum  in  some  cases  of  chronic 
bronchitis  is  strikingly  suggestive  of  tuberculosis.  Furthermore,  it 
frequently  happens  that  cases  of  pulmonary  tuberculosis  with  com- 
plicating chronic  bronchitis  and  bronchiectasis  exhibit  the  characteristic 
sputum  of  such  conditions,  especially  the  abundant  quantity  and  the 
separation  upon  .standing  into  distinct  layers. 

The  expectoration  is  expelled  with  apparent  ease  in  some  cases  and 
with  conipui'utive  difficulty  in  others.  This  is  dependent  to  some 
extent  upon  the  pathologic  change  in  the  pulmonary  tissues,  the  degree 
and  nature  of  bronchial  disturbance,  and  the  temperament  of  the 
individual. 

In  cases  with  abundant  moisture  in  the  bronchial  tubes,  with  pro- 
nounced softening  or  beginning  cavity  formation,  the  expectoration 
is  often  raised  with  but  little  effort.  This  is  also  true  whenever  the 
coexisting  bronchitis  is  of  the  moist  variety.  Expectoration  is  con- 
spicuously easier  in  phlegmatic  individuals  than  in  the  neurotic. 

In  cases  of  dry  bronchitis  with  marked  bronchial  irritation  the 
secretion  is  not  only  less  copious,  but  decidedly  more  difficult  to  raise. 
The  expectoration  from  cavities  and  bronchiectases  may  be  attended 
with  considerable  expulsive  effort.  In  some  cases  this  is  attended 
with  violent  paroxysms,  while  in  others  the  cavities  are  emptied,  almost 
in  toto,  by  mere  change  of  posture  and  beginning  cough.  In  cases  of 
pneumopyothorax  with  free  opening  into  a  bronchial  tube  there  is 
usually  but  little  difficulty  in  exiielling  the  secretions. 

In  a  consideration  of  the  composition  of  sputum,  chief  importance 
attaches,  of  course,  to  the  tuliercie  bacillus,  but  the  presence  of  elastic 
fibers,  streptococci,  pneumococci,  staphylococci,  and  influenza  bacilli 
is  of  great  practical  interest.  No  especial  clinical  importance  relates 
to  the  detection  of  pus-cells  or  blood-corpuscles,  detritus,  or  epithelia 
from  the  mouth,  trachea,  or  even  from  the  pulmonary  alveoli. 

It  is  quite  impo,ssible  to  infer  a  tuberculous  nature  of  the  condition 
from  the  general  appearance  of  the  sputum.  It  is  unsafe  to  hazard  an 
opinion  as  to  the  presence  of  bacilli  by  virtue  of  the  purulent  nature  of 
the  expectoration,  or  as  to  their  absence  from  its  watery  or  serous 
appearance.  Neither  is  it  safe  to  assvme  their  presence  in  individual 
cases,  no  matter  how  ap-parenlhj  riDiclu.sii-r  may  be  the  subjective 
si/mptorns  or  ■physical  signs.  Lonii-roiiliiiiinl  <.iinninations  of  the  sputum 
not  infrequently  fail  to  disclose  hdcilli  in  .^iich  cases,  while  they  often 
are  detected  in  the  sputum  of  individuals  ■presenting  no  physical  signs 
whatever.  Failure  to  find  the  bacilli  after  searching  investigation  is 
explained  by  delay  in  the  ulceration  of  the  tubercle  deposit,  and  perhaps 
in  some  cases  by  absence  of  communication  of  the  infected  area  with  a 
bronchial  tube. 

The  lack  of  conformity  between  the  phyisical  signs  and  the  bac- 
teriologic  findings  is  sometimes  remarkable.  Attention  will  be  called 
later  to  the  existence  of  very  suggestive  subjective  manifestations 
and  almost  conclusive  physical  signs  in  pulmonary  syphilis,  influenza, 
and  anthracosis,  without  the  demon.strable  presence  of  bacilli. 

The  description  of  the  tubercle  bacillus  has  been  given  in  an  earlier 


106      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION- 

chapter,  and  instructions  have  been  detailed  as  to  the  technic  of  sputum 
examination.  It  is  only  necessary  to  emphasize  again  the  importance 
of  selecting,  when  possible,  one  of  the  tiny  yellowish  or  greenish-yellow 
opaque  lumps  from  the  expectoration  and  of  securing  a  thin  smear 
upon  the  cover-glass.     It  is  a  common  fault  with  beginners  to  overstain. 

In  collecting  specimens  of  sputum  for  examination  explicit  instruc- 
tions should  be  gi\-en  to  the  patient  not  only  as  to  the  thorough  cleansing 
of  the  bottle  and  cork,  but  also  concerning  their  sterilization.  It  is 
desirable  that  the  sputum  should  be  obtained  in  the  morning  before  the 
ingestion  of  food,  and  that  the  mouth  and  throat  should  be  thoroughlj- 
rinsed  with  a  saturated  solution  of  boric  acid.  This  is  particularh' 
important  when  search  is  to  be  made  for  other  microorganisms  than 
the  tubercle  bacilli. 

The  elastic  fibers  are  often  recognized  in  the  sputum,  as  they  are 
not  destroyed  by  the  softening  process  in  the  lungs.  BaciUi  sometimes 
are  found,  however,  before  the  elastic  fibers  make  their  appearance. 
The  latter  may  be  detected  also  in  connection  with  pulmonary  abscess 
and  gangrene  of  the  lung.  They  are  commonly  recognized  by  boiling 
an  equal  quantity  of  the  sputum  with  a  strong  solution  of  potash  or 
soda,  followed  by  complete  sedimentation. 

In  some  cases  the  influenza  bacillus  is  a  factor  of  especial  importance, 
irrespective  of  the  presence  or  absence  of  tubercle  bacilli,  as  will  be 
described  under  the  subject  of  Diagnosis. 

The  .sputum  of  patients  who  present  extremes  of  fever,  sweating, 
and  other  manifestations  of  severe  constitutional  disturbances  often 
contains  streptococci,  staphylococci,  and  pneumococci.  The  recogni- 
tion of  these  micro-organisms  in  such  cases  is  a  matter  of  the  utmost 
consequence,  as  will  be  seen  in  the  chapters  devoted  to  Mixed  Infection 
and  Specific  Medication. 


CHAPTER    XVIII 
PAIN,  HOARSENESS,  AND  DYSPNEA 


Pain  in  the  chest  is  bj-  no  means  a  constant  feature  of  pulmonary 
tuberculosis,  although  many  believe  that  it  is  almost  sure  to  develop  at 
some  time  in  the  course  of  the  chsease.  There  is  no  relation  between 
this  symptom  and  the  nature  or  extent  of  the  tuberculous  involvement 
per  se.  A  more  or  less  active  pulmonary  invasion  may  exist  for  years 
without  the  slightest  admis.sion  of  pain  on  the  part  of  the  patient. 
Upon  the  other  hand,  complaint  may  be  made  by  some  individuals  in 
whom  the  physical  signs  are  exceedingly  slight.  There  is  no  special 
reason  why  involvement  of  the  pulmonary  tissue  alone  should  produce 
pain,  even  should  the  destructive  change  extend  to  the  formation  of 
cavities. 

Pain  in  the  chest  developing  in  the  course  of  pulmonary  tuberculosis 
is  almost  never  referable  to  the  damaged  lung  tissues,  but  results 
invariablj'  from  coexisting  intrathoracic  complications.     It  may  accom- 


PAIN,    HOARSENESS,    AND    DYSPNEA  107 

pany  acute  bronchitis,  any  form  of  pleural  invasion,  initial  pneumo- 
thorax, intercostal  neuralgia,  and  the  pulling  ui>on  the  diaphragm 
incident  to  violent  paroxysmal  cough,  or  it  may  exist  simply  as  an 
expression  of  a  neurotic  disturbance. 

The  pain  attending  acute  bronchitis  complicating  pulmonary 
phthisis  is  usually  felt  in  the  front  of  the  chest,  extending  from  the 
manubrium  downward  along  the  sternum.  It  may  vary  from  a  feeling 
of  rawness  with  oppression  to  a  sensation  of  actual  pain.  In  such  cases 
it  is  often  associated  with  soreness  in  the  lateral  regions  of  the  chest, 
owing  to  the  frequent  distressing  cough  incident  to  the  lironchial  affection. 

Pain  resulting  directly  from  pleuritic  involvement  is  always 
referred  to  the  affected  side  of  the  chest.  A  pleurisy,  however,  may 
exist  upon  one  side,  devoid  of  any  sensation  of  pain,  while,  as  a  result 
of  other  causes,  complaint  may  be  made  with  reference  to  the  opposite 
side.  While  pleurisy  is  not  invariably  attended  by  physical  discomfort, 
the  pains,  if  present,  are  more  or  less  sharp  and  stabbing  in  character. 
They  are  excited  particularly  upon  deep  inspiration  and  cough,  and 
relieved  by  immobilization  of  the  ribs.  If  the  pain  be  at  all  consider- 
able, the  respirations  are  interrupted  in  character  and  markedly 
restrained.  The  pain  is  not  referred  in  all  cases  to  the  precise  site  of 
the  pleural  involvement.  I  have  repeatedly  recognized  the  friction 
rub  of  a  dry  pleurisy,  and  yet  have  been  unable  to  obtain,  either 
during  forced  respiration  or  cough,  any  admi.s.sion  of  pain  in  the 
vicinity  of  the  evident  pleural  involvement.  The  pain  may  be  absent 
entirely  or  referred  to  an  inferior  jioint  in  the  cliest,  even  to  the  extreme 
lower  margin  of  the  ribs.  Occasic.nully  I  have  found  the  pain  upon 
cough  and  respiration  ascribed  to  the  hiinl.,'ii'  legion  and  lower  abdomen. 
As  is  well  known,  moderately  large  pleuial  effusions  may  exist  without 
the  slightest  subjective  evidence  of  their  pi-esence. 

The  pain  of  an  initial  pneumothorax  resulting  from  perforation 
of  the  pleura  is  usually  of  a  most  severe  and  excruciating  character, 
and  attended  by  symptoms  of  profound  prostration  or  collapse.  In 
such  cases  the  pain  may  not  be  referred  to  a  single  point,  but  may  extend 
throughout  the  entire  affected  side.  A  frequent  site,  however,  is  in 
the  region  of  the  heart.  Accompanying  the  pain  in  the  side  is  the 
familiar  oppression  or  "air-hunger."  resulting  from  the  sudden  collapse 
of  the  lung  before  its  fellow  of  the  opposite  side  has  been  aljle  to  adjust 
itself  to  the  radically  increased  respiratory  demand.  It  should  be 
remembered,  however,  that  pneumothorax  may  occur  without  causing 
pain  or  aiiv  other  pronounced  siihjective  symptom.  .Many  times  I 
have  been  impie.ssed  by  this  striking  plieiionienon,  winch  is  contrary 
to  the  usual  conception  regarding  llie  clinical  onset  ol  pneumothorax. 
It  is  noteworthy  that  many  such  c<,mliti..ns  have  developed  while  the 
patient  was  lying  q\iictl\-  in  ImmI  wiiliont  exliil.ifing  severe  or  distressing 
cough,  and  not  havim;  ex|ierience(l  musculai-  strain  of  any  kind. 

Paroxysmal  cough,  resulling  IVom  more  or  less  extensi\e  <>avity 
formation,  bronchiectasis,  and  pronounced  bronchial  iiiitatiuii  is  fre- 
quently responsil)le  for  the  prodm-tiou  of  pain.  This  is  usually  referred 
to  the  lower  lateral  ))ortion  of  the  chest,  and  very  likely  is  cau.sed  by  the 
increa.sed  tension  at  the  attachment  of  the  diaphragm. 

Intercostal  neuralgia  may  exist  among  pulmonary  invalids  as  in 
those  who  enjoy  ordinary  health.  It  is  pre.sent  chiefly  in  the  region 
of  the  nipple  and  in  the  middle  or  lower  zone  of  the  thorax.     Like  the 


108      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

pain  of  pleurisy,  it  may  produce  a  decidedly  restrained  respiration  for 
the  time  being,  but  the  absence  of  fever  and  physical  signs  usually 
suffices  for  its  accurate  determination. 

Finally,  complaint  of  pain  is  made  by  a  type  of  individuals  who 
exhibit  evidences  of  a  nervous  temperament,  and  often  with  a  well- 
marked  functional  derangement.  The  pain  may  not  be  localized 
definitely,  and  even  may  vary  in  its  location  during  short  intervals. 
If  limited  to  a  single  region,  it  is  often  stated  to  exist  in  the  lower 
portion  of  the  thorax,  far  removed  from  the  site  of  any  recognizable 
tuberculous  lesion.  Frequently  the  pain  is  referred  to  the  region  of  the 
liver.  Sometimes  it  is  said  to  be  present  near  the  lower  angle  of  the 
scapula  or  in  the  region  of  the  nipple,  but  rarely  at  the  apex.  When 
ill  defined  and  vague  in  character,  it  usually  occurs  more  as  a  hyperes- 
the.sia  of  the  skin  than  as  actual  pain,  and  is  said  by  the  patient  to  be 
increased  upon  percussion  or  pressure  with  the  stethoscope. 

VOICE  SYMPTOMS 

Alterations  in  the  voice  are  of  considerable  frequency,  and  vary 
from  slight  temporary  changes  in  quality  and  intensit}'  to  marked 
hoarseness  or  complete  aphonia. 

Hoarseness  is  sometimes  one  of  the  early  symptoms  of  tuberculosis, 
but  it  may  appear  at  any  time  during  the  course  of  the  disease  or  be 
entirely  absent.  Change  in  the  character  of  the  voice  may  be  so 
slight  as  to  be  scarcely  appreciable,  or  so  great  as  to  effect  a  complete 
transformation  of  tone,  rendering  the  sound  harsh  and  discordant. 

The  chief  interest  attaching  to  hoarseness  as  a  symptom  of  consump- 
tion relates  to  its  precise  cause  and  duration.  By  far  the  most  important 
factor  in  its  production  is  a  coexisting  tuberculosis  of  the  larynx.  By 
virtue  of  the  general  anemic  condition  of  the  larynx,  a  paresis  of  the 
adductor  muscles  may  account  for  the  early  hoarseness  long  before  a 
definite  suspicion  is  entertained  of  either  a  laryngeal  or  a  pulmonary 
tuberculous  involvement.  Somewhat  later  an  infiltrative  process  may 
occasion  a  slight  tumefaction  in  the  posterior  commissure,  preventing 
complete  adduction  of  the  vocal  bands,  and  producing  a  distinct  change 
in  the  quality  of  the  voice.  The  tuberculous  infiltration  may  extend  to 
the  vocal  bands  themselves,  producing  thickening  and  congestion,  or 
to  the  muscles  which  control  the  movements  within  the  larynx.  Finally, 
distinct  ulcerations  may  take  place  along  the  free  margin  of  the  vocal 
bands.  (For  further  discussion  of  Laryngeal  Tuberculosis  see  Com- 
plications.) 

Hoarseness  is  frequent  in  the  course  of  pulmonary  phthisis  in  the 
absence  of  tubercle  deposit  within  the  larynx.  It  may  occur  as  the 
result  of  complicating  acute,  subacute,  or  chronic  laryngeal  catarrh, 
producing  congestion  and  thickening  of  the  bands,  precisely  as  in  non- 
tuberculous  individuals.  The  hoar-seness  may  be  intensified  for  brief 
periods  by  the  pre.sence  of  i-etained  secretions  upon  the  vocal  bands, 
preventing  their  perfect  apposition.  Changes  in  the  quality  of  the 
voice,  due  to  this  cause,  disappear  in  part  after  the  act  of  coughing  or 
clearing  the  throat,  and  particularly  when  the  larynx  has  been  thoroughly 
cleansed  by  a  spray.  Hoarseness  may  be  e.xperienced  as  a  result  of 
muscul.ir  fatigue  from  the  overuse  of  the  voice  following  loutl  speaking 
or  prolonged  reading. 


PAIN,    HOARSENESS,    AND    DYSPNEA  109 

In  the  absence  of  definite  visual  changes  recognizable  within  the 
larynx,  the  quality  and  intensity  of  the  voice  become  impaired  in  many 
consumptives  toward  the  later  stages  of  the  disease,  on  account  of 
the  extreme  systemic  debility.  In  such  cases  the  hoarseness  may  be 
regarded  as  an  expression  of  the  general  prostration,  as  in  other 
severe  constitutional  diseases. 

Paralysis  of  the  cords  may  result  from  the  implication  of  a  recur- 
rent laryngeal  nerve  in  the  pleuritic  thickenings  and  adhesions  at  the 
pulmonary  apex. 

It  is  almost  unnecessary  to  state  that  the  degree  of  hoarseness, 
whatever  its  cause,  offers  no  possible  criterion  of  the  nature  or  extent 
of  the  pulmonary  infection.  As  a  matter  of  fact,  a  decided  amelioration 
of  the  phthisical  condition,  as  shown  by  the  physical  signs,  sometimes 
follows  the  onset  of  laryngeal  tuberculosis.  As  a  general  rule,  a  gain 
in  the  local  condition  takes  place  commensurately  with  general  improve- 
ment. 

DYSPNEA 

Changes  in  the  frequency  of  the  respirations  are  more  or  less  constant, 
though  subject  to  marked  variation  in  individual  cases.  The  quickened 
rate  may  extend  from  a  slightly  accelerated  breathing  to  true  dyspnea. 
The  latter  is  usually  associated  with  cyanosis,  and  upon  trifling  exertion 
the  auxiliary  muscles  of  respiration  are  called  upon  to  respond  to  the 
respiratory  needs  of  the  patient. 

Like  other  symptoms,  dyspnea  has  no  fixed  relation  to  the  extent 
of  morbid  change  within  the  thorax.  It  is  common  to  observe  patients 
with  an  astonishing  destruction  of  lung  tissue  and  apparently  an  extensive 
reduction  of  respiratory  area  with  but  little,  if  any,  shortness  of  breath. 
Others  may  display  but  slight  physical  evidence  of  disease  and  yet 
exhibit  a  marked  degree  of  respiratory  embarrassment.  Some,  in  spite 
of  a  very  rapid  pulse,  boast  that  they  are  as  "  long  winded' '  as  in  former 
health,  while  others  have  but  limited  respiratory  capacity,  notwithstand- 
ing the  fact  that  the  pulse  may  be  slow  and  of  excellent  quality. 

Neither  fever  nor  anemia  offers  any  reliable  criterion  by  which  to 
form  conclusions  regarding  the  dyspnea  of  consumptives.  In  general, 
however,  certain  conditions  are  found  to  exert  an  unquestioned  influence 
in  its  causation.  One  of  the  most  important  of  these  is  a  material 
diminution  of  the  re.spiratory  surface.  In  this  event  the  essential  con- 
sideration is  not  so  much  the  extent  of  the  respiratory  limitation  as  the 
suddenness  of  its  development.  The  time  in  which  the  respiratory  capac- 
ity is  reduced  constitutes  the  fundamental  element  in  determining  the 
extent  of  the  resulting  dyspnea.  Thus  many  patients  may  be  observed 
with  numerous  areas  of  impaired  lung  as  a  result  of  prolonged  pulmo- 
nary tuberculosis,  or  with  one  lung  rendered  entirely  inactive  by  a  slowly 
developing  pleural  effusion,  or,  still  further,  with  wonderfully  diminished 
bilateral  respiratory  capacity  as  a  result  of  chronic- interstitial  pneu- 
monia, and  yet  suffering  but  slight  inconvenience  from  shortness  of 
breath.  The  reason  is  apparent  from  the  fact  that  the  obliteration  of 
the  respiratory  surface  takes  place  so  slowly  that  the  unaffected  portion 
of  lung  is  able  to  adapt  itself  to  the  changed  conditions,  and  respond  in 
a  measure  to  the  increasing  needs  which  are  imposed  upon  it.  To  illus- 
trate the  impossibility  of  perfect  adaptation  and  response  when  the 
respiratory  function  is  embarrassed  by  the  sudden  involvement  of  large 


110      SYMPTOMATOLOGY    AND    COUHSE,    VARIETIES    AND    TERMIxNATION 

pulmonary  areas,  it  is  only  necessary  to  cite  the  alarming  dyspnea 
incident  to  pneumonia,  and  the  air-hunger  with  collapse  resulting 
from  sudden  pneumothorax.  Therefore  the  dyspnea  of  pulmonary 
tuberculosis,  while  produced  in  part  by  the  consolidation  or  destruction 
of  lung  tissue,  yet  in  some  cases  may  correspond  but  little  to  the  extent 
of  pathologic  change. 

Pulmonary  invalids  often  ask  for  an  explanation  of  their  dj'spnea, 
the  issue  involved  in  the  mind  of  the  patient  being  a  determination  as 
to  whether  the  shortness  of  breath  is  due  to  the  pulmonary  involvement, 
to  the  heart,  or  to  other  conditions.  It  is  sometimes  cUfficult  to  arrive 
at  a  satisfactory  conclusion  as  to  the  precise  relation  of  the  several 
factors  jointly  responsible  for  its  production.  A  weak  and  rapid  heart 
is  unquestionably  an  important  cause  in  many  cases,  especially  if  renal 
disturbances  coexist.  Fever  is  known  to  make  the  respirations  more 
shallow  and  more  frequent.  Profound  anemia  is  associated  with  short- 
ness of  breath  on  account  of  the  resulting  deficient  oxygenation.  Upon 
this  theory  alone  it  is  hard  to  explain  the  dj-spnea  of  tuberculosis,  for 
the  examination  of  the  blood  rarely  shows  a  change  proportionate  to  the 
pronounced  outward  manifestations  of  anemia. 

The  shortness  of  breath  is  often  more  noticeable  in  neurotic  than 
in  phlegmatic  patients,  and  is  intensified  by  excitement  or  mental 
emotion.  Many  patients  are  oljserved  who  experience  not  the  slightest 
respiratory  embarrassment  so  long  as  they  are  at  rest,  but  who  suffer 
from  distressing  shortness  of  breath  upon  slight  exertion.  I  do  not 
regard  this  feature  of  itself  as  a  contraindication  for  moderate  altitudes, 
provided  the  pulse  is  satisfactory  and  evidences  of  general  improvement 
are  established,  but  rather  as  an  emphatic  indication  for  absolute  rest 
regardless  of  location. 

The  dyspnea  of  tuberculosis  is,  of  course,  subject  to  considerable 
variation  according  to  the  coexisting  complications. 

In  chronic  bronchitis  the  increased  frequency  of  respiration  is  induced 
to  a  large  extent  by  the  obstruction  occasioned  in  the  finer  bronchioles 
by  the  thickened  mucous  membrane  and  the  presence  of  secretion. 
The  progress  of  air  into  the  pulmonary  alveoli  is  thus  obstructetl  to 
some  extent,  and  its  exit  even  more,  as  the  normal  act  of  expiration 
is  essentially  passive  in  character.  The  expiratory  effort  is  exerted 
largely  upon  the  bronchioles,  thus  throwing  additional  strain  upon  the 
pulmonary  alveoli.  This,  in  connection  with  coincident  nutritional 
change,  produces  in  time  an  unavoidable  emphysema. 

In  proportion  as  emphysema  develops,  either  with  or  without  asthma, 
will  the  severity  of  the  dyspnea  increase.  This  is  also  intensified  liy 
the  extension  of  small  areas  of  bronchopneumonia,  whether  of  tuber- 
culous or  of  inflammatory  origin. 

Dyspnea  following  a  pulmonary  hemorrhage  is  attributable  in  some 
instances  to  the  development  of  septic  aspiration  pneumonia.  The 
dyspnea  is  increased  moderately  in  pleural  effusion,  and  usually  to  an 
extraordinary  degree  by  the  onset  of  pneumothorax. 

It  has  been  mentioned  that  in  acute  miliary  tuberculosis  of  pneu- 
monic type  the  dyspnea  is  out  of  all  proportion  to  the  physical  evidences 
of  the  clisease.  This  would  suggest  that  the  shortness  of  breath  is  not 
to  be  accounted  for  entirely  by  the  diminution  of  respiratory  area,  but 
to  some  extent  by  the  irritation  of  the  terminals  of  the  vagus  by  reason 
of  widely  disseminated  miliary  tubercles.  Pressure  upon  the  vagus  by 
enlarged  bronchial  glands  may  produce  the  same  result. 


CHAPTER   XIX 
FEVER 

Fever,  by  virtue  of  its  overwlielming  prognostic  significance,  sur- 
passes in  importance  all  otlu-r  syniptoius  of  consumption.  Persisting 
elevation  of  tenqierature  furnishes  nmrc  rclia,l)le  evidence  upon  which 
to  base  unfavorable  conclusions  regartling  ultimate  success  than  any 
other  clinical  feature  in  the  course  of  pulmonary  tuberculosis.  A  con- 
tinuous fever  is  an  insuperable  obstacle  to  recovery.  The  development 
of  fever  is  known  to  be  entirely  independent  of  the  physical  signs,  the 
stage  of  the  disease,  or  the  nature  and  extent  of  pathnlogic  change. 
Most  extensive  areas  of  active  tuberculous  infection  may  cxi>i  wiihotit 
any  appreciable  elevation  of  temperature.  A  severe  ((institutional 
disturbance,  however,  may  accompany  a  slight,  inactive  tuberculous 
process.  Many  attempts  have  been  made  to  offer  a  satisfactory 
explanation  of  the  origin  of  fever,  to  account  for  its  presence  or 
absence  in  different  cases  and  in  the  same  individual  under  varying 
conditions,  to  classify  arbitrarily  its  several  forms,  and  to  ascril)e  to 
particular  types  a  fixed  correspondence  with  certain  pathologic  and 
bacteriologic  conditions.  Tims  far  siu'li  efforts  have  not  proved  entirely 
convincing  from  a  clinical  stamlpoint.  It  is  difficult  to  explain  authori- 
tatively why  it  is  present  in  some  cases  :;ii(l  not  in  others;  why  the  same 
patient  may  exhibit  an  elevation  of  teiiiiiei.'itnre  i'or  weeks,  to  be  followed 
by  an  unexpected  decline  for  variaMe  |ieiio(ls;  why  in  thoM'  alilicted 
it  is  absent  in  the  morning,  only  to  rise  in  the  al'teiiioon ;  why  there  is 
no  relation  between  its  presence  and  the  \aiious  cHnical  stages  of  the 
disease,  and  why  it  should  exhibit  so  striking  a,  dissiniilarity  in  various 
cases,  rather  than  conform  to  the  characteristics  of  a  single  type.  No 
effort  will  be  made  to  explain  the  precise  manner  of  its  production  and 
the  diversity  of  its  exhibition.  Practical  interest  at  this  time  attaches 
more  to  the  clinical  manifestations  of  fever  and  its  prognostic  and  thera- 
peutic significance  than  to  a  detailed  stvidy  of  the  influence  of  the  tubercle 
bacillus  and  the  microorganisms  of  mixed  infection.  Suffice  it  to  say 
that  the  fever  may  be  traced  directly  to  the  tubercle  bacillus  as  well 
as  to  the  accompany ini::  bacteria  of  mixed  infection.  Among  the  latter 
the  streptococ(  us.  st  apli}  iococcus,  and  pneumococcus  are  especially  con- 
spicuous in  its  iiro(hiction. 

The  fever  attributaWe  to  the  tubercle  bacillus  is  often  of  minor 
importance  in  comparison  with  that  occasioned  by  other  iui(  rooigaii- 
isms.  That  the  tubercle  bacillus  may  serve  as  at  least  a  conti  ibutory 
agent  in  its  development  is  suggested  i)y  the  fe\-er  of  pure  miliary  tuber- 
culosis and  the  ri.se  of  temperature  follow  iiiii  injections  of  tuberculin. 

The  fever  of  consumption  may  lie  assumed  to  be  due  primarily  to 
the  absorption  into  the  circulation  of  certain  toxic  products.  The 
height  of  the  fever  would  naturally  suggest  the  approximate  concen- 
tration of  the  poi.sons  in  the  blood  or  body-fluids.  The  degree  of 
saturation  of  the  circulatory  and  tissue  fluids  would  ordinarily  be 
regarded  as  more  or  less  commensurate  with  the  area  of  the  primary 
focus  of  infection,  the  degree  of  activity  of  the  tuberculous  process,  the 
extent  of  degenerative  change,  and  the  capacity  for  absorption  on  the 
part  of  the  individual. 


112      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

While  these  factors  in  the  absorption  of  toxic  products  may  be 
accepted  in  their  general  application,  there  exist  certain  modifying 
conditions,  capable  in  some  instances  of  producing  diverse  results. 
Thus  the  absorption  from  a  hirge  area  of  infection  may  be  much  less 
than  from  a  small  focus,  by  virtue  of  changes  in  the  tissue  immediatel}^ 
contiguous  to  the  tuberculous  process,  serving  effectually  to  impede  peri- 
pheral absorption.  These  changes  may  relate  in  some  cases  to  the  im- 
paired absorptive  capacity  or  to  an  obliteration  of  the  finer  blood-vessels. 
At  other  times  a  barrier  to  absorption  may  be  established  through  the 
concentration  of  the  poisons  in  the  tissues  immecUately  adjacent  to  the 
infected  area.  Again  the  degree  of  activity  and  the  character  of  path- 
ologic change  may  not  be  correctly  represented  by  the  degree  of  fever. 
Rapidl}'  advancing  caseation  is  often  unattended  by  fever,  provided 
there  is  ample  exit  for  the  products  of  cUsorganization  through  free 
communication  with  a  bronchial  tube.  Pulmonary  cavities  may  be 
unaccompanied  by  fever,  although  the  destructive  change  is  cpiite  exten- 
sive. This  is  particularly  true  if  the  excavation  is  surrounded  by  thick- 
ened, indurated  tissue,  affording  scant  opportunit}'  for  absorption. 
Further,  the  absorptive  power  of  individuals  varies  according  to  their 
age,  the  state  of  the  general  circulation,  and  the  degree  of  stasis  in  the 
immediate  neighborhood  of  infected  areas.  Finally,  the  specific  nature 
of  the  microorganisms  constituting  the  secondary  infection  influences 
to  a  considerable  extent  the  character  and  degree  of  fever.  These 
considerations  suggest  a  partial  though  superficial  explanation  of  the 
vagaries  of  temperature  in  consumption,  but  the  more  complete  elabora- 
tion of  their  production  is  left  to  others. 

Irrespective  of  its  precise  origin,  which  may  be  incapable  of  authorita- 
tive explanation,  the  fact  remains  that  the  fever  of  phthisis  is  a  decidedly 
variable  quantity.  .It  is  often  present  in  the  early  stages,  only  to 
disappear  later  in  the  chsease.  This  is  attributable  in  part,  though  not 
entirely,  to  the  enforced  rest,  which  is  insisted  upon  after  the  patient 
comes  under  competent  observation.  As  a  rule,  an  excessive  elevation 
of  temperature  is  observed  only  after  the  tuberculous  process  has 
become  well  advanced,  or  in  the  presence  of  inflammatory  or  septic 
complications.  The  afebrile  state  of  some  individuals  may  be  inter- 
rupted temporarily  by  various  causes,  as  an  intercurring  influenza, 
an  acute  chgestive  disturbance,  the  development  of  bronchopneumonia, 
pleurisy,  or  pneumopyothorax,  and  by  extension  of  the  tuberculous 
process  to  hitherto  uninfected  areas.  Ephemeral  elevations  of  tem- 
perature are  observed  as  a  result  of  pereonal  indiscretions  relating 
to  injudicious  exercise,  fatigue  from  any  cause,  and  nervous  excitement. 
In  some  patients  a  short  walk  or  sitting  up  in  bed,  the  entertainment 
of  callers,  card-playing,  mental  irritation,  grief,  anger,  or  an  absorbing 
book  are  sufficient  to  produce  moderate  fluctuations.  Fever  is  often 
present  during  the  period  of  menstruation,  although  a  normal  temper- 
ature is  exhibited  at  other  times.  Noticeable  differences  of  temperature 
are  noted  according  as  the  record  is  taken  out-of-doors,  after  physical 
exercise,  the  swallowing  of  hot  drinks,  the  ingestion  of  ice-cream,  or 
the  holding  of  bits  of  ice  in  the  mouth.  The  temperature  taken  with 
the  patient  in  the  cold  air  is  almost  invariably  lower  than  within  doors. 
It  also  is  elevated  perceptibly  after  moderate  exerci.se,  but  is  difficult  of 
recognition  unless  taken  by  the  rectum.  In  mouth-breathers  particularly 
it  is  almost  impossible  to  obtain  an  accurate  record  after  exercise  on 


FEVER  113 

account  of  the  appreciable  cooling  of  the  buccal  and  lingual  membrane 
incident  to  exposure  to  cold  air.  The  mouth  should  be  closed  during 
the  entire  time  that  the  thermometer  remains  in  position.  An  interval 
.  of  at  least  five  minutes  should  elapse  before  this  is  removed,  else  the 
record  becomes  extremely  unreliable. 

Rest,  both  physical  and  nervous,  is  almost  a  sine  qua  non  in  the 
effort  to  effect  a  continued  reduction  of  fever.  The  maintenance  of  the 
recumbent  position  in  bed  during  the  twenty-four  hours  of  the  day  is 
often  attencled  with  remarkable  results  in  far-advanced  cases. 

Without  attempting  too  great  refinement  in  a  classification  of  the 
various  types  of  fever  observed  among  consumptives,  it  perhaps  is 
sufficient  to  enumerate  briefly  the  following  varieties: 

The  first  class  comprises  patients  whose  temperature  is  normal 
in  the  morning  and  rises  to  the  neighborhood  of  100°  F.  or  lOOf  °  F. 
in  the  afternoon.  Such  invalids  are  frequently  unaware  of  the  exist- 
ence of  fever,  and  often  deny  this  possibility  most  emphatically  until 
convinced  by  the  use  of  the  thermometer.  There  may  be  no  flushing 
of  the  cheeks,  no  greater  sense  of  warmth,  or  other  evidence  of  dis- 
comfort from  the  increased  body-heat.  Others  present  the  history 
of  slight  chilly  sensations  preceding  the  rise  of  temperature,  followed 
by  flushing  and  burning  of  the  cheeks,  dryness  of  the  mouth  and  lips, 
lassitude,  slight  dyspnea,  and  more  or  less  actual  discomfort. 

A  second  class  may  be  described  as  exhibiting  an  intensification  of  the 
fever  of  the  preceding  type.  The  temperature  rises  in  the  afternoon  to 
102°  F.  or  103°  F.,  and  recedes  in  the  morning  to  the  neighborhood  of 
100°  F.,  or  sometimes  to  normal.  The  fever  is  frequently  preceded 
by  chilliness,  and  attended  by  other  unpleasant  sensations,  but  not 
invariably.  Patients  are  usually  conscious  of  the  elevated  temperature, 
and  sometimes  experience  considerable  physical  discomfort,  as  head- 
ache, disagreeable  sense  of  warmth,  anorexia  in  the  afternoon,  and 
general  indisposition.  These  types  of  fever  may  be  present  during 
any  stage  of  consumption. 

In  a  class  of  cases  the  fever  may  assume  still  another  clinical  form. 
In  the  morning  it  is  considerably  below  normal,  beginning  its  ascent 
more  or  less  abruptly  in  the  middle  of  the  day,  and  rising  until  evening 
to  103°  F.  or  104°  F.  The  fever  of  this  class  is  more  likely  to  be  preceded 
by  a  distinct  chill,  or  at  least  by  pronounced  chilly  sensations,  than 
that  of  any  other  variety.  As  a  rule,  the  patient  is  exhausted  in  the 
morning,  pale  or  somewhat  cyanotic,  with  marked  coldness  of  the 
hands  and  feet.  The  fall  of  fever  is  likely  to  be  associated  with  drenching 
sweats,  which  may  occur  at  any  time  during  the  night,  but  more  par- 
ticularly in  the  earh'  morning.  This  is  known  as  the  fever  of  absorption 
or  mixed  infection,  and  is  described  as  hectic,  corresponding  to  the 
so-called  septic  fever  of  surgeons.  It  has  been  tlKuuiht  to  be  attended 
almost  constantly  by  softening  or  rapi(ll>-  :i(l\aii<ing  excavation,  but 
such  is  not  always  the  case.  I  have  repeats lly  seen  this  variety  of 
fever,  even  in  early  cases,  without  the  slightest  suggestion,  upon  examina- 
tion, of  cavity  formation  or  softening,  while  patients  with  advancing 
infection  and  excavation  often  fail  to  display  this  type  of  fever. 

Another  variety  of  fever  is  characterized  by  a  continuous  high 
elevation  of  temperature  at  all  hours  of  the  day.  There  may  be  a 
remission  of  one  or  two  degrees  in  the  morning,  but  the  recession  is 
rarely  to  normal.     The  fever  of  this  class  is  accompanied  almost  invar- 


114      SYMPTOMArOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

iably  by  increasing  dyspnea  and  cyanosis,  and  is  frequently  exhibited 
by  patients  suffering  from  an  acute  bronchopneumonic  complication. 
In  some  instances  these  cases  from  the  beginning  are  found  to  par- 
take of  the  characteristics  of  acute  pneumonic  phthisis.  It  is  not 
altogether  unusual  to  observe  the  development  of  an  acute  pneumonic 
extension  of  the  tuberculous  process  in  patients  previously  mani- 
festing a  chronic  type  of  consumption.  A  patient  who  for  years 
had  been  afflicted  with  pulmonary  tuberculosis  exhibiting  subjec-tive 
and  physical  evidences  of  a  quiescent  infection  experiencetl,  without 
warninu;,  a  severe  rigor,  followed  bj-  an  abrupt  rise  of  temperature  to 
104|°  F.  Examination  of  the  lungs  shortly  disclosed  a  distinct  pneu- 
monic consolidation  in  the  left  front.  At  no  time  afterward  did  the 
temperature  recede  in  the  morning  more  than  one  or  two  degrees,  while 
the  dyspnea  increased,  emaciation  became  rapid,  and  cyanosis  with 
exhaustion  were  increasingly  apparent.  At  the  end  of  one  week  the 
physical  evidences  of  softening  were  recognized  in  the  consolidated 
lung,  and  expectoration,  which  previously  had  been  absent,  became 
very  profuse.  At  the  time  of  his  death,  which  took  place  three  weeks 
after  the  initial  onset  of  the  pneumonic  extension,  cavity  signs  were 
readily  detected. 

Sometimes  cases  are  observed  in  which  the  temperature  is  decidedly 
irregular.  The  chief  clinical  characterization,  as  far  as  fever  is  con- 
cerned, may  relate  to  an  elevated  temperature  in  the  morning,  followed 
by  an  evening  remission.  In  some  cases,  however,  this  so-called 
inverse  type  of  fever  may  be  followed  for  several  days  by  morning 
remissions  and  evening  exacerbations.  Such  irregularities  of  tempera- 
ture may  develop  in  patients  who  previously  exhibited  no  fever  whatever. 
This  suggests  the  possibility  of  a  general  miliary  infection  super\-ening 
in  the  course  of  the  pulmonary  disease.  The  fever  may  be  associated 
with  vague,  indefinite  symptoms  of  malaise,  languor,  indispo-sition,  and 
digestive  disturbances  simulating  typhoid,  or  it  may  be  attended  by 
headache,  pain  in  the  back  of  the  neck,  delirium,  stupor,  and  motor 
symptoms  of  meningeal  tuberculosis.  It  may  also  be  accompanied  by 
cough,  with  slight  expectoration  and  a  disproportionate  dyspnea  and 
cyanosis,  the  physical  signs  Ijeing  those  of  a  widely  diffused  bronchitis. 
This  hitter  combination  of  symptoms  is  highly  suggestive  of  a  miliary 
infection  with  predominant  manifestations  in  the  lungs. 

Other  types  of  fever  have  been  mentioned  by  various  observers,  and 
a  fixed  clinical  significance  attached  to  the  respective  varieties.  A 
comparison  of  the  forms  above  enumerated  is  sufficient  to  convince 
one  of  the  obvious  difficulty  in  (li-;(i  iniinirinu-  sharply  between  some 
of  these  clinical  types.  Further  etTint-  iliici  icd  toward  a  conventional 
classification  lead  to  increased  (•<iniusi(iii  Summaiy  conclusions  as 
to  unvarying  pathologic  association  are  not  warranted  by  the  results 
of  clinical  ob-servation.  It  must  be  remembered  that  the  es.sential 
consideration  in  the  production  of  fever  is  the  entrance  into  the  circula- 
tion of  the  toxic  products,  anil  that  the  extent  of  their  absorption  does 
not  always  correspond  to  the  character  of  morbid  change.  It  is  not 
always  easy  to  distinguish  the  exact  nature  of  the  secondary  infection. 
In  some  cases  streptococci  are  found  in  abundance  in  the  sputum,  as 
are  also  the  staphylococci,  pneumococci,  and  other  microorganisms. 
Examinations  of  the  blood  may  disclose  the  particular  type  of 
s?'-)tic?mi'i  present,  as  may  also  examinations  of  the  pleural  exudate. 


EMACIATION    AND    LOCAL    OBJECTIVE    SYMPTOMS  115 

Not  infrequently  the  sputum,  collected  in  sterile  bottles  after  thorough 
cleansing  of  the  mouth  before  the  ingestion  of  food,  has  sliown  lumicrous 
streiDtococci  and  othei'  microorganisms,  although  not  the  slightest  clinical 
eviclence  of  sepsis  had  lict'ii  cstablisliod.  On  the  othci-  liand,  many 
patients  have  di^|ila\i'd  ilic  chai'arii.iisi  ir  icniiiciaiiM-c  (if  mixed  infec- 
tion, with  assciriatcd  rliills  aiid  swcals.  \\illi(nit  ihc  ivcognition  of 
secondary  microorganisms  ui  the  sputum.  This  subject  will  be  con- 
sidered under  i\lixed  Infection. 


CHAPTER  XX 
EMACIATION  AND  LOCAL  OBJECTIVE  SYMPTOMS 

EMACIATION 

Loss  of  weight  is  one  of  the  inipnrtaiit  s\niptoms  of  consumption. 
It  bears  several  definite  relations  t"  thr  luliciculous  process.  Emacia- 
tion, with  corresponding  imjiaiiiiiciit  i>\  Uic  ^I'licral  rosistnnce,  renders 
the  patient  (hsuin'tly  mon.  susccpiiMc  to  the  ori-innl  tuberculous 
invasion.  The  iiilrctioii  once  cstalilishcd,  coiiiriiiiiic  ^  iiliiio-l  unavoid- 
ably to  a  further  loss  ol'  weight.  linally,  the  only  ralioiKil  iiiothod  of 
securing  an  ultimate  airest  of  the  tuberculous  process  is  ilie  main- 
tenance of  an  iiiipio\ed  nutrition.  On  account  of  tliese  established 
relations  between  the  weight  inu\  the  pulmonary  condition  it  is  easy  to 
appreciate  the  overwhelming  impoitaiice  of  judicious  superalimentation. 
With  but  few  exceptions  does  the  emaiiatiiin  go  hand  in  hand  with  an 
advancing  activity  of  the  tubeiculous  iiifei-fiou.  It  is  true  that  some 
patients  exhibit  pliysii-ij  e\iileiices  of  lapiilly  extemling  pulmonary 
disease  without  dis])la>imj:  loi  a  time  any  coii-ideiable  impairment 
of  body  weight.  Occasioually  1  have  noteil  w  ide-r|iieail  iiixolvement 
of  the  lungs  with  extensive  destruction  of  tissues  iu  \eiy  corpulent 
individuals,  but  such  instances  are  decidedly  exn  ptioii.il.  Rarely 
are  patients  fni-funate  enough  to  spctire  an  afi-e'-t  of  the  I  ubei-culous 
process  without  tlie  .-it  l  ;uniueut  of  -ic;itly  iuiprowil  uutiitioii.  If  so, 
it  is  found,  upon  iin-e-li-atiou,  tliat  ,-^uc. ■(■-.-,  a,-  a  lule.  results  i,n/  ajler 
an  attciiijiU,!  <,iili,rr  to  iucivase  ImmI\-  weight,  but  df.^pdt'  the  lack  of  any 
effort  ill  tius  .lireriiiiu.  111  ,,iliei'  words,  the  patient  posse!3sing  well- 
marked  power-  of  ri.-i-i:iiiie  cliaiices  to  secure  the  arrest  of  an  inci]iipnt 
infection  without  being  compelled  to  resort  to  a  method  which  is  invalu- 
able to  the  majority  of  cases.  It  m.i\-  \»-  ad<led  that  p.itiems  re(  o\-er- 
ing  from  consumption  without  manifesting  gain  in  weight  are  almost 
invariably  free  from  fever  and  have  not  displayeil  any  appreciable 
loss  of  their  average  weight. 

The  relation  of  fever  to  general  nutrition  is  of  vast  significance, 
the  loss  of  weight  usually  corresponding  to  the  height  and  persistence 
of  the  temperature  elevation.  Tliis  relation  exists  nut  only  beeause  of 
the  impaired  appetite  and  dige-iiou.  but  al~o  by  \iitiie  of  the  faei  that 
both  the  fever  and  the  emaciation  are  <liiectly  dei)endent  ujiou  the 
ab.sorption  of  toxic   products.     As  long  as  the   fever  continues  it  is 


116      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

extremely  difficult  to  overcome  the  depraved  nutrition  even  to  a  slight 
extent. 

The  emaciation  relates  first  to  the  loss  of  subcutaneous  fat,  but 
this  does  not  obtain  to  an  equal  degree  in  all  parts  of  the  body.  In 
some  individuals  the  face  retains  surprisingly  its  normal  contour,  while 
the  limbs  and  body  become  distressingly  thin.  In  other  cases  the  con- 
figuration of  the  face  is  distinctly  changed,  the  features  assuming  a 
characteristic  drawn  and  pinched  appearance,  while  the  outline  of  the 
limbs  is  not  proportionately  affected.  In  regaining  weight  the  improved 
condition  is  sometimes  noted  in  the  face  without  appreciable  change  in 
the  body  or  limbs,  while  in  others  the  face  is  the  last  to  exhibit  improved 
nutrition.  It  is  well  to  observe  carefully  in  all  cases  the  appearance  of 
the  neck  and  hands,  the  former  often  showing  in  a  strikingly  impressive 
manner  the  effect  of  advancing  emaciation. 

As  the  flesh  is  regained  there  is  a  noticeable  tendency  toward  the 
accumulation  of  adipose  tissue  over  the  abdomen  and  hips.  The 
increased  weight  is  rarely  distributed  with  impartiality  over  the  entire 
body.  This  is  due  largely  to  the  lack  of  exerci.se  and  the  consequent 
deficient  muscvilar  development.  In  fact,  the  emaciation  is  occasioned 
in  part  by  the  atrophy  of  the  muscles  from  disuse,  and  with  returning 
weight  the  limbs,  by  virtue  of  the  enforced  rest,  fail  to  assume  their 
normal  contour,  the  superabundant  fat  then  being  accumulated  over 
the  abdomen. 

LOCAL  OBJECTIVE  SYMPTOMS 

The  local  manifestations  pertaining  to  pulmonary  tuberculosis 
which  are  not  at  the  same  time  subjective  in  type  are  comparatively 
unimportant.  They  may  be  said  to  constitute  matters  of  clinical 
interest  rather  than  of  especial  practical  significance.  A  few  of  these 
symptoms  are  perhaps  worthy  of  some  allusion. 

One  of  the  most  striking  phenomena  is  the  frequent  changed  appear- 
ance of  the  ends  of  the  fingers.  The  peculiar  contour  of  the  terminal 
phalanges  has  been  described  as  "clubbed,"  and  is  believed  to  be  char- 
acteristic of  tuberculosis.  This  in  a  measure  is  quite  incorrect,  as  in 
uncomplicated  pulmonary  tuberculosis  it  is  rare  to  observe  genuine  club- 
bing of  the  finger-tips.  Care  should  be  taken  to  discriminate  between 
the  so-called  clubbing  of  the  fingers  and  the  marked  forward  incurvation 
of  the  nails.  Properly  speaking,  the  term  "clubbed  fingers"  refers  to 
a  pronounced  thickening  of  the  terminal  phalanges  referable  entirely 
to  the  soft  parts,  without  change  in  the  shape  and  size  of  the  nail. 
This  is  not  altered  in  any  material  respect,  l:>ut  the  ends  of  the  fingers 
give  the  appearance  of  being  .shortened  and  broadened.  The  nails 
are  almost  invariably  perfectly  straight  and  but  little  cyanosed.  This 
type  of  finger  is  found  in  connection  with  chronic  or  fetid  bronchitis 
and  bronchiectasis,  either  existing  alone  or  complicating  tuberculosis. 
The  change  which  is  more  definitely  characteristic  of  consumption 
is  the  long,  slender,  and  tapering  finger,  devoid  of  any  suggestion  of 
thickening,  but  with  pronounced  incurving  of  the  nails,  which  are 
usually  somewhat  cyanosed.  In  pulmonary  tuberculosis  it  is  not 
uncommon  also  to  note  long,  slim,  and  narrow  hands,  with  slender 
but  non-tapering  fingers,  both  with  and  without  incurving  nails. 

The  skin  of  the  tulierculous  patient  is  usually  dry,  although  the 
hands  are  often  cold  and  clammy.     This  element  of  dryness  is  char- 


EMACIATION    AND    LOCAL    OBJECTIVE    SYMPTOMS 


actei'istic  of  the  hair  and  nails,  which  are  also  brittle.     As  emaciation 
the  skin  becomes  somewhat  wrinkled;  as  anemia  increases 


Kig.  2.— Draw- 
clubbing  of  the  t 
posterior  thickening. 


it  is  more  sallow  or  even  cachectic,  and  with  advancing  cardiac  or  respir- 
atory embarrassment  it  is  more  cyanosed  and  sometimes  edematous. 


118      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

Cyanosis  and  edema  will  lie  alluded  to  under  Symptoms  Referable  to 
the  Circulation. 

The  facial  aspect  and  coinplcrion  may  vary  more  or  less  according  to 
the  particular  type  of  the  tuberculous  disease.  In  those  with  pronounced 
lymphatic  involvement  the  features  are  coar.se,  the  nose  l)road,  the  lips 
thick,  the  ceneral  contour  of  the  face  somewhat  gross,  ami  the  complexion 


muddy.  In  the  distinctly  phthisical  type  the  skin  is  often  extremely 
fair,  with  the  subcutaneous  veins  especiallj^  prominent,  and  sometimes 
the  face  suffused  with  a  hectic  flush. 

A  not  infrequent  condition  is  the  browish-yellow,  dry.  scaling 
rash  of  pityriasis  versicolor,  most  abundant  upon  the  anterior  ])ortion 
of  the  chest  or  abdomen. 


EMACIATION    AND    LOCAL    OBJECTIVE    SYMPTOMS 


119 


fonti 
othei 


of  the  chest  tiny  fihrillary 
,rc  sometimes  ohservcd.  In 
from  the  ixiiiit  of  iiercii.ssion 


to  the  farthest  extremity  of  the  muscle.  This  is  regarded  as  a  phenome- 
non of  degeneration,  and  is  produced  Ijy  the  hyperirritability  of  the 
atrophied  muscle. 


120      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 


CHAPTER  XXI 
CIRCULATORY  DISTURBANCES 

The  symptoms  attributable  to  the  circulation  observed  in  pulmonary- 
tuberculosis  are  acceleration  of  the  pulse  in  the  absence  of  recognized 
cardiac  lesions,  changes  in  the  heart  itself,  including  its  dislocation, 
symptoms  of  resulting  stasis,  and,  finally,  pulmonary  hemorrhage. 

Increased  rapidity  of  the  pulse-rate  due  to  various  causes  may 
occur  at  any  period  during  the  course  of  the  disease.  It  is  often  noted 
in  very  early  stages,  and  when  unassociated  with  other  symptoms 
or  physical  signs  is  frequently  regarded  as  indicative  of  a  threatening 
tuberculous  invasion.  The  truth  is  that  in  many  such  instances  the 
patient  is  already  the  subject  of  tubercle  deposit,  the  evidences  of 
which  thus  far  have  been  incapable  of  precise  determination. 

The  acceleration  of  the  pulse  may  vary  from  a  slightly  increased 
frequency  to  the  point  of  genuine  tachycardia.  In  some  cases  the 
rapid  pulse-rate  is  temporary  in  duration,  being  subject  to  con- 
siderable variation,  accortling  to  external  conditions.  While  gradual 
improvement  is  sometimes  observed  in  the  absence  of  exciting  causes, 
it  often  happens  that  the  increased  rapidity  persists  indefinitely.  This 
symptom,  when  present,  con.stitutes  one  of  the  most  important  features 
of  pulmonary  tuberculosis.  It  possesses  vast  prognostic  import,  and 
suggests  more  imperatively  even  than  fever  the  necessity  of  absolute 
rest.  "  It  often  occurs  independent  of  fever  or  in  the  absence  of  pro- 
nounced physical  signs.  When  occurring  in  very  early  stages,  it  rarely 
is  associated  with  an  acceleration  of  respiration.  Many  patients,  how- 
ever, with  considerable  elevation  of  temperature  and  marked  evidences 
of  active  tuberculous  infection,  fail  to  exhibit  this  symptom  to  any 
extent. 

The  pulse  is  usually  soft  and  easily  compressible,  the  blood-pressure 
apparatus  registering  a  low  arterial  tension  in  the  majority  of  cases. 
In  some,  however,  it  is  full  and  bounding,  with  associated  cardiac 
excitability,  the  exaggerated  heart  action  at  once  being  recognized 
by  the  stethoscope.  This  form  is  more  frequently  observed  either  in 
connection  with  fever  incident  to  inflammatory  disturbance  or  in  a 
few  highly  excitable  and  neurotic  subjects.  Not  infrequently  the  heart 
appears  unduly  stimulated,  the  scmiu^  liciiiii  ndticoaMy  louder  and  the 
impulse  intensified  to  such  an  extent  n-  to  1)I(m1uc(>  a  distinct  ri.se  and 
fall  of  the  stethoscope  with  each  iml;a!i<iii.  The  soft  and  easily  com- 
pressible pulse  is  also  noted  in  connection  with  more  or  less  waste  of 
nutrition  and  general  exhaustion. 

Acceleration  of  the  pulse  is  an  especially  common  symptom  among 
young  pulmonary  invalids,  in  whom  it  i-^  snliject  to  much  variation. 
It  is  found  to  be  increased  by  sliiiiii  i\eiri-e  m-  nervous  excitement. 
It  may  be  produced  by  card-pla\  iiil;.  ainniated  conversation,  emo- 
tion, or  the  ingestion  of  a  hearty  meal.  The  pulse  in  such  cases 
is  usually  slow  in  the  morning,  but  .suddenly  becomes  accelerated 
upon  the  advent  of  exciting  causes.  In  innumerable  instances  I  have 
found  not  only  that  rest  is  necessary  in  order  to  reduce  this  disturbance 
to  a  minimum,  but  a  degree  of  isolation  as  well,  even  to  the  exclusion 


CIRCULATORY    DISTURBANCES  121 

of  the  few  social  diversions  permitted  to  pulmonary  invalids.  As  a 
result  of  the  disturbed  systemic  circulation,  engorgement  of  the 
liver  not  infrequently  takes  place.  A  persisting  enlargement  of  this 
organ  from  passive  congestion  is  undoubtedly  of  very  unfavorable 
prognostic  import. 

In  some  cases  the  increased  pulse-rate  may  be  extreme  without 
being  associated  with  dyspnea  or  other  subjective  symptoms  sufficient 
to  excite  the  attention  of  the  patient.  In  other  instances  there  are 
restlessness,  dyspnea,  cardiac  palpitation,  and  inability  to  sleep.  I 
have  in  mind  the  case  of  a  woman,  thirty-five  years  of  age,  who  came 
to  Colorado  in  1899  with  moderate  involvement  of  each  lung  and  but 
slight  elevation  of  temperature.  On  account  of  extreme  prostration 
she  was  accompanied  upon  her  journey  by  her  attending  physician. 
Upon  their  arrival  I  was  informed  that  for  many  weeks  it  had  been 
necessary  for  her  to  maintain  the  recumbent  position  on  account  of  a 
very  rapid  pulse  with  associated  distressing  symptoms.  The  pulse 
remained  from  160  to  180  for  several  weeks,  although  there  was  no 
cardiac  lesion.  It  was  impossible  for  the  patient  to  sit  up  without 
alarming  symptoms  of  collapse.  Liquid  food  was  taken  through  a  drink- 
ing tube.  Emaciation  was  extreme,  the  patient  weighing  but  seventy- 
five  pounds.  Heart  stimulation  was  employed  tentatively,  but  relief 
was  obtained  chiefly  through  the  cautious  administration  of  opiates. 
During  the  four  years  that  she  remained  under  my  observation  she 
exhibited  a  progressive  improvement,  gaining  eighty  pounds  in  weight, 
securing  a  complete  arrest  of  the  tuberculous  process,  with  entire  relief 
of  the  tachycardia,  althovigh  residing  in  a  distant  part  of  the  State  at 
an  altitude  of  7500  feet — one-third  higher  than  Denver. 

Increased  frequency  of  the  rate  usually  fails  to  respond  to  the 
employment  of  therapeutic  remedies  calculated  to  slow  the  pulse,  but 
often  yields  to  the  influence  of  rest  and  non-depressing  sedative  agents. 

Acceleration  without  cardiac  involvement  may  be  due  in  part  to 
fever,  anemia,  the  toxins  incident  to  the  tubercle  bacilli  and  mixed 
infections,  pressure  upon  the  vagus  from  tuberculous  rriediastinal  glands, 
and  reduced  intra-arterial  pressure.  I  have  been  impressed  by  the 
uniform  diminution  of  blood-pressure  exhibited  by  my  patients  in  a 
series  of  examinations  recently  made.  It  would  seem  that  to  some 
extent  this  condition  may  exist  as  a  partial  factor  in  the  production 
of  an  increased  pulse-rate. 

Irregularity  of  the  pulse  during  the  course  of  consumption  occurs 
comparatively  seldom  in  connection  with  increased  frequency.  Occa- 
sionally it  may  exist,  however,  as  may  also  pronounced  slowin.u  of  the 
pulse.  At  this  time  I  am  attending  a  lady  in  middle  life  who  is  .securing 
a  very  satisfactory  degree  of  arrest  following  extensive  active  involve- 
ment of  both  lungs,  with  considerable  excavation.  For  months  there 
have  been  an  absence  of  fever,  marked  diminution  of  cough  and  expec- 
toration, pronounced  gain  in  weight,  and  evidences  of  an  extensive 
fibrosis.  Of  late  she  has  developed  a  ilisiurliiuii  irregulai'ity  of  the 
pulse,  which  has  also  become  very  much  slower  than  formerly,  and  is 
ranging  in  the  neighborhood  of  40.  I  have  been  able  to  recognize  no 
lesion  of  the  heart,  and  the  cau.se  of  the  bradycardia  remains  purely 
a  matter  of  conjecture,  although  the  probability  of  myocarcUtis  is 
apparent. 

Weakness  of  the  heart  maj'  develop  as  a  result  of  the  general  exhaus- 


122      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

tion,  for  excessive  loss  of  weight,  fever,  and  anemia  inevitably  produce 
anatomic  changes  in  the  heart  muscle.  In  cases  of  profound  toxemia 
marked  degenerative  changes  are  likely  to  result.  Many  observers, 
following  Brehmer's  example,  have  reported  a  diminution  in  the  size 
of  the  heart  of  phthisical  patients. 

Endocarditis  is  not  especially  uncommon  as  a  complication  of 
pulmonary  tuberculosis,  in  many  instances  the  condition  resulting 
through  the  influence  of  secondary  infection.  In  addition  to  the 
actual  valvular  changes  incident  to  the  endocardial  invoh-ement,  a 
systolic  murmur  is  often  detected  in  the  region  of  the  pulmonary  valve, 
especially  if  anemia  is  profound.  An  accentuated  second  sound  is 
exceedingly  common  on  account  of  the  obstruction  to  the  circulation 
in  the  pulmonaiy  artery  and  the  consequent  increased  arterial  pressure. 
As  an  indirect  result  of  the  obstructed  blood-current  in  the  pulmonary 
artery  eventual  dilatation  of  the  right  ventricle  may  ensue,  and  tri- 
cuspid regurgitation  may  also  develop.  The  embarrassed  pulmonary 
circulation  is  seen  more  freciuently  in  cases  of  considerable  pneumonic 
consolidation,  extensive  filiro-^is,  and  emphysema,  as  in  these  conditions 
especially  are  the  dcniand-  upon  the  right  heart  more  insistent. 

Varying  degrees  ni  -t:i  i-  in  llie  lesser  circulation  arise  as  the  direct 
effect  of  well-defined  cardiac  disturbance,  although  to  this  cause  there 
sometimes  is  added  a  hydremic  condition  of  the  blood.  Congestion  of 
the  pulmonary  circulation  results  chiefly  from  a  disproportionate 
weakness  of  the  left  side  of  the  heart.  The  blood  being  forced  back 
into  the  pulmonary  veins,  there  is  necessarily  an  obstruction  to  the 
onward  flow  in  the  pulmonarj'  arteries,  which  causes  hypertrophy  and 
final  dilatation  of  the  right  ventricle.  The  condition  known  as  passive 
congestion  of  the  lungs  is  essentially  the  result  of  mechanical  obstruction 
to  the  pulmonary  circulation  arising  from  cardiac  weakness  with  or 
without  mitral  lesion. 

The  symptoms  of  this  condition  are  usuall}'  indefinite  in  character, 
although  cyanosis  and  increasing  dyspnea  are  often  manifest.  Pains- 
taking examination  of  the  chest  may  disclose  at  the  bases  a  diminished 
intensity  of  the  respiratory  sounds,  with  slight  changes  in  pitch  and 
quality.  A  moderate  amount  of  moisture  in  the  finer  bronchioles 
may  be  detected  in  this  region.  If  the  congestion  is  extreme,  par- 
ticularly when  associated  with  fever  and  certain  inflammatory  conditions 
complicating  tuberculosis,  changes  take  place  in  the  dependent  portions 
of  the  lung,  to  which  the  term  "hypostatic  congestion"  is  applied. 
This  is  especially  likely  to  result  when  the  patients  are  bedridden  and 
essential  changes  are  recognized  upon  examination.  These  consist  of 
impaired  resonance  upon  percussion  over  the  affected  areas,  diminution 
or  absence  of  respiratory  sounds,  which,  if  rocoiiiiizod.  are  almost  tubu- 
lar in  quality,  with  elevation  of  pitch  and  chanire  of  rhythm,  and 
attended  also  by  an  abundance  of  bubbling  rales.  In  such  cases  the 
cyanosis  and  dyspnea  are  very  apparent.  The  cough  is  loose  and  pro- 
ductive, the  expectoration  being  frothy,  with  occasional  slight  tinges  of 
blood.  This  condition  may  be  associated  with  small  areas  of  consoli- 
dated pulmonary  tissue.  The  hypostatic  congestion  is  usually  bilateral, 
unless  the  patient  is  accustomed  to  lie  for  long  periods  upon  one  side. 

Edema  of  the  lungs,  consisting  of  transudation  of  the  watery 
constituents  of  the  blood  into  the  bronchial  tubes,  may  result  from  the 
combined  effect  of  several  causes.     It  may  appear  at  times  of  great 


PULMONARY  HEMORRHAGE  123 

debility,  with  pronounced  anemia,  or  perliaps  in  association  with 
advanced  kidney  lesions,  or  it  may  result  from  an  acute  bronchopneu- 
monia. It  may  be  observed  at  times  as  the  direct  effect  of  a  sudden 
loss  of  heart  power  from  any  cause.  In  several  instances  I  have  noted 
this  cUstressing  condition  as  a  delayed  result  of  pulmonary  hemorrhage, 
though  in  such  cases  a  more  direct  cause  should  be  ascribed  to  the 
developing  bronchoiinfMuiiciiiia  ronsequent  upon  the  aspii:ili<iii  <ir  Mood. 
I  have  seen  its  develuinncm  lullciwing  carefully  graduated  suImuimucous 
injections  of  salt  soluliim,  winch  were  imperatively  demanded  ti>  nyev- 
come  an  alarming  collapse  aUemliug  the  enormous  loss  of  blood  incident 
to  pulmonary  hemonha.iie.  Smh  a  clinical  phenomenon  would  appear 
to  be  rather  in  line  wiili  the  observations  of  those  who  report  increasing 
general  edema  follo\\iii,i;  the  administration  of  salt  solution  in  nephritis. 

The  symptoms  eon-ist  of  intense  dyspnea,  cyanosis,  and  cough. 
The  expectoration  is  usually  copious,  distinctly  frothy,  and  tinged 
with  bright  blood.  There  is  dulness  upon  percussion,  and  frequently 
absence  of  breath-sounds,  with  innumerable  bubbling  rales,  chiefly 
at  the  bases.  Loud,  coarse  bubbling  sounds  referred  to  the  trachea, 
commonly  called  the  death-rattle,  may  attend  the  respiratory  effort. 

As  a  remote  effect  of  cardiac  weakness  there  is  seen  general  edema 
of  the  ankles,  feet,  hands,  and  even  of  the  face.  The  swelling  of  the 
face,  as  well  as  of  the  extremities,  is  not,  as  a  rule,  perfectly  symmetric. 
One  foot  or  ankle  is  usually  swollen  considerably  more  than  the  other. 
This  is  often  true  of  the  hands  as  well.  The  swelling  of  the  face  may  he 
recognized  upon  one  side  before  the  other  shows  any  evidence  of  edema. 
Cyanosis  of  the  face  is,  of  course,  present  to  a  like  degree  upon  both  sides, 
as  well  as  in  the  finger-nails.  A  unilateral  flushing  of  one  cheek,  how- 
ever, due  to  vasomotor  change,  without  other  evidence  of  cardiac 
disturbance,  is  frequently  witnessed. 


CHAPTER  XXII 
PULMONARY  HEMORRHAGE 

Allusion  has  been  made  to  the  frequent  hemorrhagic  onset  of  pul- 
monary tuberculosis.  It  has  been  made  clear  that  hemoptysis  may 
take  place  at  any  time  in  the  course  of  the  chsease,  api)ai-eiitly  without 
regard  to  the  extent  or  nature  of  the  morbid  pulmonaiy  chaiiiie.  Its 
development  is  entirely  independent  of  siil)jecli\-e  syiHptoliis  oi'  physical 
signs.  It  ma\-  occur  in  the  absence  of  lexer.  coii.i:li.  (  inacaai  ion.  pul- 
monary excavation,  and  I'ccognized  cai'diac  or  ciri'ulatoi}-  disturbance. 
Even  in  the  midst  of  seeming  healtli  and  vigor  alarming  hemorrhages 
are  not  uncommonly  experienced,  a  copious  loss  of  blood  suggesting 
the  probability  of  a  ruptured  pulmonary  aneurysm.  Upon  the  other 
hand,  many  consumptives  are  permitted  to  linger  for  years  without 
hemorrhagic  experience,  although  the  lungs  are  known  to  have  undergone 
very  extensive  destructive  change. 

Various  observers  have  reported  the  proportion  of  pulmonary  invalids 
suffering  from  hemorrhage  to  be  from  20  to  80  per  cent.     In  considering 


124       SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

such  diverse  statements,  due  allowance  should  be  made  for  the  widely 
differing  conditions  under  which  the  respective  groups  of  patients 
were  observed. 

It  is  easy  to  understand  why  hemorrhages  should  be  decidetUy  more 
frequent  among  invalids  who  are  not  subject  to  disciplinary  control 
than  among  those  confined  within  closed  sanatoria.  The  striking 
disparity  recorded  as  to  the  frequency  of  hemorrhages  within  and 
without  sanatoria  has  been  asserted  to  be  incident  purely  to  the 
supervisory  regime  practised  in  such  institutions.  It  is  probable, 
however,  that  the  incipient  character  of  these  cases  is  account- 
able in  part  for  the  disproportionate  observation.  In  addition,  the 
admirable  discipline  enforced  in  sanatoria  is  of  undoubted  benefit  in 
greatly  minimizing  the  tendency  to  hemoptysis.  According  to  the 
rigidity  of  supervision,  either  within  or  without  institutions,  hemor- 
rhages are  invariably  less  frequent.  In  the  experience  of  those  who 
have  been  privileged  to  observe  a  large  number  of  cases  outside  of 
sanatoria  it  has  been  found  that  hemorrhagic  patients  always  exhibit 
a  remarkable  improvement  in  this  respect  upon  the  inauguration  of 
supervisory  control.  My  own  experience,  which  was  reported  in  1901, 
embodied  the  analysis  of  457  hemorrhagic  cases  occurring  at  some  time 
in  the  course  of  the  disease,  out  of  a  total  number  of  900  patients,  20  per 
cent,  of  whom  exhibited  a  distinctly  hemorrhagic  onset  of  their  pul- 
monary affection.  Three  himdred  and  eighty-six  cases,  or  over  82  per 
cent.,  occurred  before  the  patients  came  under  my  observation.  Of 
these,  only  97,  or  one  in  four,  suffered  subsequent  recurrences. 

Sometimes  there  is  observed  a  rather  striking  periodicity  in  the 
development  of  hemorrhages.  Long  periods  with  but  comparatively 
few  and  insignificant  hemoptyses  have  been  followed  repeatedly  by  a 
disqiueting  frequency  of  these  manifestations  among  my  patients, 
suggesting  more  than  a  mere  coincidence.  No  bacteriologic  studies 
thus  far  have  sufficiently  explained  such  periodic  evolution  of  symptoms, 
although  pneumococci  have  been  demon.strated  by  Ravenel  to  be 
present  in  some  hemorrhagic  cases.  I  have  noted  the  more  frequent 
occurrence  of  these  hemorrhages  in  Colorado  during  the  spring  months, 
coincident  with  abrupt  changes  in  the  weather.  For  many  years  I 
have  been  led  to  regard  their  greater  frequency  at  this  season,  cor- 
responrliii-  with  periods  of  variability  in  temperature,  increased  wind 
movement,  aii.l  auitation  of  dust,  as  explainable  in  part  by  a  relation 
of  cause  and  etffct.  At  such  times  I  have  been  forced  earnestly  to 
admonish  patients  against  imdue  exposure  to  wind  and  dust. 

The  form  or  extent  of  pidmonary  hemorrhage  varies  from  a  slight 
spitting  of  blood  to  an  immediately  fatal  termination  resulting  from 
the  perforation  of  a  pulmonary  aneurysm. 

As  a  rule,  but  little  importance  is  attached  by  physicians  to  slight 
bloody  discolorations  of  the  sputum.  A  great  difference  is  observed, 
however,  among  consumptives  in  the  mental  effect  produced  even  by 
apparently  insignificant  hemorrhagic  manifestations.  The  presence  of 
but  little  blood  in  the  expectoration  is  sufficient  with  some  not  only 
to  induce  an  unfortunate  mental  disquietude,  but  even  to  arouse  the 
wildest  fears,  sometimes  to  the  point  of  utter  demoralization.  Others 
who  have  become  more  or  less  accustomed  to  occasional  hemopty.ses 
apparently  attach  but  trifling  importance  to  the  expulsion  of  several 
mouthfuls  of  blood.     Many  patients,  priding  themselves  upon  their 


PULMONARY  HEMORRHAGE  125 

past  experiences,  are  inclined  to  view  succeeding  hemorrhages  v.'ith 
manifest  indifference  and  to  disregard  precautionary  admonitions 
calculated  to  prevent  their  recurrence  and  minimize  their  severity. 
Either  of  these  extreme  attitudes  on  the  part  of  the  invalid  is  especially 
unfortunate,  in  view  of  the  difficulty  experienced  in  inculcating  a 
correct  and  rational  conception  as  to  the  true  significance  even  of  slight 
hemoptysis.  In  all  cases  where  there  is  any  considerable  admixture 
of  blood  in  the  expectoration  it  has  been  my  habit,  regardless  of  the 
history  of  previous  hemorrhages,  to  acquaint  the  patient  in  a  reassuring 
but  conservative  manner  with  the  possibility  of  approaching  hemoptysis. 
I  have  learned  to  regard  these  bloody  discolorations  of  the  sputum  in 
many  instances  as  precursory  manifestations  of  a  severe  hemorrhage, 
which  may  often  be  avoided  upon  the  adoption  of  precautionary 
measures.  It  has  been  my  custom  to  inform  patients  affecting  a  disdain 
for  these  occurrences  that  the  early  slight  hemoptysis  is  analogous  to 
the  warning  signal  displayed  in  front  of  an  approaching  train,  which 
may  be  ignored  only  through  risk  of  imminent  peril.  The  impending 
danger  relates  not  to  the  slight  hemoptysis  itself,  but,  like  the  pre- 
cautionary signal,  to  its  significance.  Many  threatening  hemorrhages 
have  been  avoided  by  an  immediate  insistence  upon  rest,  diet,  and 
other  details  of  management. 

Moderate  hemorrhages  may  occur  at  any  time,  either  following 
exercise,  mental  excitemmit,  violent  cough,  a  hearty  meal,  absolute 
quiet,  or  during  sleep.  r5y  moderate  hemorrhages  are  meant  the 
expectoration  of  from  four  to  eight  ounces  of  bright  arterial  blood. 
While  some  hemorrhages  of  this  character  may  result  from  prolonged 
and  violent  coughing,  others  are  entirely  unassociated  with  cough  only 
in  so  far  as  the  hemorrhage  itself  serves  to  furnish  an  exciting  cause. 
Injudicious  exercise  and  excitement  must  be  regarded  as  potent  factors 
in  the  production  of  hemoptysis,  on  account  of  the  increased  arterial 
tension  often  induced.  Many  patients  present  a  history  of  hemorrhage 
from  prolonged  and  rapid  walking,  lifting,  running  to  catch  a  car, 
riding  a  bicycle,  driving  an  automobile  or  a  fast  horse,  or  other  forms 
of  physical  exercise  and  recreation.  Others  suffer  a  similar  experience 
as  a  result  of  undue  nervous  excitement  incident  to  attendance  at  the 
matinee  or  ball-game,  card-playing,  heated  argument,  grief,  or  excessive 
worry.  Hemoptysis  is  induced  not  uncommonly  by  inhalation  of  the 
overheated  and  vitiated  air  of  public  buildings  and  conveyances.  I 
have  had  occasion  to  note  this  occurrence  in  several  instances  at  public 
gatherings,  upon  street-cars,  steam  conveyances,  and  in  poorly  ventilated 
apartments.  Despite  the  enforcement  of  a  disciplinary  regime,  numer- 
ous hemorrhages  have  taken  place  among  my  patients  while  sitting 
quietly  in  a  reclining  chair  or  resting  in  a  recumbent  position  upon  a 
couch.  Not  infrequently  they  have  occurred  in  the  absence  of  all 
mental  or  nervous  disturbance,  and  even  during  profound  sleep..  I 
recall  several  instances  of  fatal  pulmonary  hemorrhage  developing  in 
the  midst  of  deep  slumber.  While  a  history  of  disturbing  dieams 
is  sometimes  elicited,  the  patient  in  many  cases  is  overcome  by  an  inun- 
dating sanguineous  flood  during  unconscious  repose.  Distinct  pre- 
monitory symptoms  of  pulmonaiy  lifniinili.'iiic  -avc  piilirely  absent, 
as  a  rule.  There  may  be  a  brief  initial  li'diiiii  nt'  npincssion  in  the 
chest,  followed  by  a  sensation  of  wanntli  umlci-  the  stcinum,  a  saltish 
taste  in  the  mouth,  and  expectoration  of  bright   l)lood,   which  rises 


126       SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

nipidl}-  in  the  throat  and  is  expelled  in  mouthfuls.  The  cough  is  more 
or  less  choking,  rattling,  excitable,  and  sometimes  even  explo.sive  iu 
character.  The  bleeding  ma}'  persist  for  several  minutes,  and  disappear 
altogether,  or.  after  an  interval  of  quiet,  it  may  be  followed  by  one  or 
several  recurrences.  From  my  experience  in  moderately  high  altitudes 
I  have  been  led  to  expect,  after  the  lapse  of  a  few  hours,  at  least  one  or 
two  repetitions  of  the  initial  hemorrhage  before  the  bleeding  may  be 
regarded  as  under  satisfactoiy  control.  The  expectoration  of  clots  or 
blood-stained  sputum  usually  persists  for  several  days  after  the  arterial 
hemorrhage  has  ceased.  The  clots,  which  are  dark  in  color,  heavy, 
and  airless,  gradually  diminish  in  quantity  and  become  lighter  in  color 
until  the  expectoration  is  free  from  blood. 

After  motlerate  or  .severe  hemorrhages  the  sputum  does  not  always 
assume  its  previous  gross  characteristics,  certain  changes  in  the  quantity 
and  appearance  being  discerned.  The  expectoration  may  be  diminished  or 
increased,  and  its  nature  either  more  distinctl,v  purulent  or  more  frothy 
than  prior  to  the  hemoptysis.  A  notable  reduction  of  cough  and  expectora- 
tion is  not  uncommon  after  the  lapse  of  several  weeks.  The  abatement  of 
former  paroxysmal  cough  is  often  conspicuous.  A  previous  frothy  expec- 
toration sometimes  cUsappears  almost  entirely  after  a  brisk  hemorrhage, 
presumably  on  account  of  the  depletion  of  congested  pulmonary  areas. 
Upon  the  other  hand,  purulent  secretions  in  the  respiratory  tract,  as 
a  rule,  are  increased  for  protracted  periods.  Upon  the  advent  of 
bronchopneumonia  from  the  aspiration  of  blood  into  the  finer  bronchioles 
the  expectoration  ceases  altogether.  Upon  the  development,  however, 
of  pulmonary  edema,  the  expectoration  becomes  copious  in  amount  and 
frothy  in  character,  with  noticeable  bloody  discoloration. 

The  most  severe  form  results  from  the  perforation  of  a  pulmonary 
aneurysm  or  the  rupture  of  a  fair-sized  artery  traversing  a  pulmonary 
cavity.  These  hemorrhages  are  often  immediately  fatal,  the  patient 
being  literally  drowned  in  his  own  lalood.  They  occur  without  the 
slightest  warning,  and  after  a  few  moments  of  inexpressiljle  anguish  all 
may  be  over.  If  the  bronchial  tubes  are  not  completely  inundated 
by  the  uncontrollable  torrent  of  blood,  there  still  remains  the  imminent 
danger  of  death  from  complete  exsanguination  and  collapse.  In 
institutions  accepting  patients  in  all  stages  of  consumption  it  is  not 
uncommon  that  the  unfortunate  victim  of  this  t\-pe  of  hemorrhage  is 
found  in  the  morning  to  have  experienced  the  terrible  onslaught  during 
sleep,  and  to  have  expired  without  warning  and  without  assistance. 
It  is  astonishing,  however,  to  note  what  enormous  quantities  of  blood 
may  be  lost  during  a  single  hemorrhage  without  causing  death.  In 
many  instances  I  have  witnessed  the  loss  of  over  a  quart  of  blood 
at  such  a  time,  which  was  followed  at  short  intervals  by  recurrences  of 
almost  incredible  amount.  In  such  cases  the  blood  is  seen  literally  to 
gush  from  the  mouth  and  nostrils,  the  choking  being  extreme,  and 
the  .spectacle,  to  say  the  least,  terrifying  and  revolting.  The  cough  is 
essentially  explosive  at  such  a  time,  large  quantities  of  blood  being 
precipitated  in  all  directions.  Several  times  I  have  seen  the  blood 
expelled  with  violence  over  the  foot  of  the  bed.  bespattering  the  wall 
of  the  room  and  saturating  the  clothing  of  the  nurse  and  attendants. 
During  such  a  hemorrhage  it  is  inevitable  that  a  considerable  portion 
of  the  blood  finds  its  way  into  the  stomach,  and  vomiting  further 
intensifies  the  cUstressing  experience.     Provided  the  invalid  does  not 


PULMONARY  HEMORRHAGE  127 

succumb  immediately  to  asphyxiation  or  shoclv,  sufficient  clotting  may 
ensue  to  produce  a  temporary  cessation  of  the  hemorrhagic  flood.  In 
this  event  the  patient  is  more  or  less  in  collapse,  greatly  exsanguinated, 
the  countenance  pallid,  respiration  sighing,  pulse  exceedingly  weak 
and  rapid, — if,  in  fact,  this  is  at  all  palpable, — skin  clammy,  extremi- 
ties cold,  and  the  face  and  brow  covered  with  copious  perspiration. 
In  such  cases  it  has  been  my  lot  to  observe  several  times  a  complete 
disappearance  of  the  pulse  for  several  hours,  complete  unconscious- 
ness, and  violent  delirium,  followed  by  recovery  from  the  hemor- 
rhage and  ultimate  arrest  of  the  underlying  tuberculous  process. 
Several  individuals  enjoying  an  active  and  useful  existence  ha\'e  in 
years  past  undergone  experiences  similar  to  the  above,  but  in  the  vast 
majority  of  instances  hemorrhages  of  this  character  are  attended  by  a 
speedy  fatal  termination.  Profound  nervous  and  ment.nl  ilisfuib.'nices 
accompanying  pulmonary  hemorrhage  are  not,  as  a  I'lilc,  fninicnt, 
although  occasionally  observed.  Delirium  is  marked  onlj-  after  exces- 
sive bleeding,  and  then  rarely.  I  recall  but  few  instances  of  this  kind. 
A  patient  has  recently  experienced  one  of  these  almost  indescribalile 
hemorrliages  during  sleep.  The  delirium  was  immediately  violent 
and  m;iiii:i(:;l.  the  iinnlid  fi)r  five  or  six  hours  shouting  at  the  top  of  his 
voice,  ami  i  he  siiimhis  being  interrupted  1)v  repeated  hemorrhages.  The 
initial  loss  uf  blood  was  cun.siderably  in  excess  of  one  quart.  The  iwlse 
could  not  1)6  felt  for  an  liour.  and  1  reilainly  exiieded  eveiy  moment 
to  be  his  last.  After  exees.-ive  stimulation  and  the  .•Mhuiiii- 1 1  ;iiion 
of  a  large  amount  of  morphin  comparati\e  quiet  was  restored,  and  upon 
the  following  day  the  patient  could  not  remember  the  occurrences  of 
the  preceding  twenty-four  hours,  not  even  to  having  experienced  a 
pulmonary  hemorrhage.  Another  patient,  a  lady  of  forty-two  years, 
after  a  copious  and  exceedingly  alarming  hemorrhage,  icniaiiied  mark- 
edly delirious  for  two  weeks.  Suicidal  mania  has  been  exliibited  in 
several  cases  as  a  direct  result  of  the  hemorrhage.  \Miile  hysteria, 
melancholia,  or  functional  nervous  disturbances  do  not  often  occur 
during  severe  pulmonary  hemorrhage,  their  subsequent  development 
is  not  infrequent. 

Pulmonary  hemorrhages  should  be  considered  further  with  reference 
to  their  uiimrdwir  and  n mote  effects. 

The  immediate  effects  consist  of  the  essential  danger  to  life  attend- 
ing the  occurrence  of  this  unfortunate  complication.  The  first  danger 
is  that  of  asi)liyxiatioii  from  inundation  of  the  bi-onchial  tubes.  This 
is  followed  bj^  the  possibility  of  sudden  collapse  from  the  shock  incident 
to  the  more  or  less  complete  exsanguination.  Upon  survival  of  these 
early  dangers  there  exists  the  problem  of  general  exhaustion.  In  my 
own  experience,  by  far  the  most  imminent  peril  attaching  to  the 
occurrence  of  pulmonary  heniiirrhage  is  the  alarming  frequency 
with  which  bronchopneumonia  develops.  This  much-to-be-feared 
complication,  which,  following  a  hemorrhage,  is  almost  universally 
fatal,  may  supervene  entirely  irrespective  of  the  size  of  the  hemorrhage 
or  the  previous  condition  of  the  patient.  No  one  can  foretell  that 
the  aspiration  form  of  pneumonia  wdll  not  terminate  life  after  hemor- 
rhages which  are  apparently  benign  in  type.  Several  times  have 
I  observed  its  dread  onset  following  the  expectoration  of  but  a  few 
ounces  of  blood  in  patients  with  little  tuberculous  infection.  Others, 
despite  a  greatly  reduced  physical  condition,  have  survived  numerous 


128      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

hemorrhages  without  its  development.  This  complication  may  appear 
insidiously,  or  its  onset  may  be  displayed  with  abrupt  symptoms. 
I  have  never  seen  it  develop  later  than  the  fourth  day.  The  fever  may 
rise  suddenly  on  the  second  day,  and  remain  elevated  in  the  neighbor- 
hood of  103°  or  104°  F.,  or  the  temperature  may  begin  a  gradual  ascent 
upon  the  third  or  fourth  day.  After  two  or  three  days  of  rising 
temperature  following  the  hemorrhage,  the  respirations  become  corres- 
pondingly rapid  and  the  pulse  greatly  accelerated,  weak,  and  easily 
compressible.  The  face  at  first  is  suffused,  and  later  becomes  cya- 
notic. The  countenance  in  the  beginning  is  animated,  the  expression 
anxious,  with  the  temperament  somewhat  excitable.  The  tongue  is 
furred,  and  the  breath  heavy  and  foul,  despite  free  catharsis.  With 
increasing  cyanosis  involving  the  nails  and  face,  the  mental  condition 
often  changes  from  a  state  of  excitability  to  hebetude,  although  not 
invariably.  From  a  large  experience  with  such  cases  I  can  assert 
that  I  have  never  witnessed  a  recuri'ence  of  hemorrhage  after  the 
symptoms  of  pneumonia  have  once  become  defined.  Neither  have  I 
found  the  cough  to  be  a  factor  of  any  importance  at  this  time.  This, 
together  with  the  expectoration,  usually  disappears  entirely  with  the 
rise  of  temperature  and  continued  acceleration  of  pulse  and  respiration. 
No  pronounced  morning  remissions  of  temperature  are  exhibited,  as  a 
rule,  and  no  sweats.  The  respirations  rapicUy  become  more  labored, 
the  alee  of  the  nose  dilating  with  each  respiratory  act.  At  this  time  the 
Cheyne-Stokes  type  of  respiration  may  be  observed.  The  pul.se  often 
rises  to  160  or  over,  and  is  of  exceedingly  poor  quality,  in  spite  of  every 
effort  toward  stimulation.  Stupor,  with  or  without  delirium,  makes 
its  appearance.  The  patient,  in  the  vast  majority  of  cases,  speedily 
succumbs,  the  duration  of  the  condition  seldom  lasting  over  four  or 
five  days  after  the  onset  of  pneumonia. 

It  is  quite  unnecessary  to  demonstrate  the  physical  signs  of  pul- 
monary consolidation  in  order  to  confirm  the  suspicion  of  broncho- 
pneumonia. A  satisfactory  examination  of  the  patient  is  often 
impracticable,  on  account  of  the  difficulty  of  access  to  the  back.  The 
subjective  symptoms  above  described,  occurring  a  few  days  following 
hemorrhage,  are  amply  sufficient  to  justify  the  gravest  fears  and  the 
rendering   of   an    unfavorable   prognosis. 

The  remote  effects  of  pulmonary  hemorrhage  are  varied  to  a  con- 
siderable extent,  its  influence  upon  ultimate  prognosis,  therefore,  being 
somewhat  uncertain.  While  unquestionably  good  results  may  occa- 
sionally follow  severe  hemorrhages,  such  happy  effects  are,  upon  the 
whole,  infrequent. 

It  has  been  stated  by  some  that  hemorrhagic  cases,  as  a  whole,  may 
be  expected  to  do  better  than  the  non-hemorrhagic.  If  true,  this  is 
explained  in  part  by  the  fact  that  the  onset  of  a  brisk  hemorrhage 
early  in  the  disease  may  lead  to  a  realization  of  the  necessity  of 
rational  management.  I  have  been  unable  personally  to  ascribe 
to  hemorrhage  cases  as  a  class  any  distinctly  favorable  or  unfavor- 
able influence  upon  the  ultimate  prognosis.  Of  my  cases  taken  as 
a  whole,  irrespective  of  the  question  of  hemorrhage,  68.5  per  cent, 
have  been  reported  as  showing  improvement.  By  this  is  meant  a 
material  lessening  of  the  activity  of  the  tuberculous  process,  as  dis- 
closed b}^  the  physical  signs,  a  diminution  of  cough  and  expectoration, 
a  reduction  of  pulse  and  temperature,  with  increased  appetite,  digestion, 


PULMONARY  HEMORRHAGE  129 

and  weight.  On  account  of  the  heterogeneous  nature  of  the  cases, 
most  of  them  far  advanced  in  type,  it  is  perhaps  better,  for  the  purposes 
of  comparison,  in  this  connection  not  to  confine  the  analysis  merely 
to  the  completely  arrested  cases.  Of  the  hemorrhagic  cases,  which 
constitute  a  little  over  50  per  cent,  of  the  total  number,  67.8  per  cent, 
have  been  reported  as  improved.  This  comparison  in  itself  fails  to 
indicate  any  special  influence  of  the  hemorrhage  upon  the  course  of 
the  disease.  It  is  noteworthy  that  one-fifth  of  these  hemorrhages 
occurred  as  the  initial  symptom  of  tuberculosis,  and  impelled  the  patient, 
apparently  in  good  health,  to  adapt  himself  without  delay  to  a  method 
of  living  appropriate  for  pulmonary  invalids,  thus  establishing  a  rela- 
tively high  percentage  of  improvement  for  this  particular  class  of 
hemorrhagic  cases.  On  the  other  hand,  numerous  specific  instances 
illustrate  clearly  the  remote  deleterious  effects  of  hemorrhage  occurring 
later  in  the  course  of  the  disease.  It  should  be  remembered  that 
hemorrhage  per  se  is  but  one  of  many  manifestations  peculiar  to  a  dis- 
ease which  exhibits  widely  differing  pathologic  conditions.  This  single 
symptom,  associated  with  all  manner  of  complicating  conditions,  is  pos- 
sessed, in  different  individuals,  of  varying  degrees  of  clinical  importance. 
In  exceptional  cases  the  hemorrhage  has  been  found  to  exert  an  influence 
for  good,  as  shown  by  diminished  cough  and  expectoration,  lessened 
temperature,  improved  appetite,  and  increase  in  weight.  It  is  some- 
times possible  to  date  the  beginning  of  definite  improvement  from  the 
onset  of  pulmonary  hemorrhage,  but  in  general  its  prognostic  significance 
in  advanced  phthisis  is  distinctly  unfavorable.  There  inevitably  results 
a  decided  loss  of  weight  from  the  diminished  alimentation,  and  a  pro- 
nounced diminution  of  resistance  from  the  more  or  less  prolonged 
confinement.  Digestion  is  usually  impaired  for  a  time  by  the  employ- 
ment of  opiates,  which  are  necessitated  by  the  frequent  irritating 
cough.  While  in  many  instances  a  gradual  return  to  previous  conditions 
may  rea.sonably  be  expected,  the  intercurrent  complication,  neverthe- 
less, has  constituted  an  unfortunate  interruption  to  forward  progress, 
involving  in  all  cases  loss  of  time,  and  in  some,  of  opportunity. 

THE  INFLUENCE  OF  CLIMATE  UPON  PULMONARY  HEMORRHAGE 

Allusion  has  been  made  to  the  relation  of  hemorrhage  to  such 
atmospheric  conditions  as  wind  and  dust.  In  addition  to  the.se  factors, 
which  may  be  regarded  as  exciting  causes,  other  climatic  attributes 
have  been  found  to  exert  an  influence  for  and  against  the  production 
of  hemorrhage.  Extreme  variability  of  temperature  is  perhaps  a 
factor  of  some  importance.  I  have  not  been  able  to  observe  any  special 
difference  in  the  frequency  of  pulmonary  hemorrhage  during  the  winter 
or  summer  months,  and  am  unable,  therefore,  to  conclude  that  the 
continued  inhalation  of  cold  air  is  at  all  instrumental  in  its  causation. 
The  sudden  changes  of  temperature,  with  an  increased  amounfof  wind 
and  dust,  incident  to  the  springtime  in  Colorado,  have  been  associated 
with  an  increased  number  of  pulmonary  hemorrhages,  giving  rise  to  a 
belief  in  the  existence  of  a  causal  relation.  Perhaps  the  chief  interest 
as  regards  the  relation  of  hemorrhage  to  climate  centers  in  the  influence 
of  altitude.  In  the  past,  the  conviction  has  been  somewhat  general 
that  altitude  directly  increases  the  frequency  of  its  occurrence.  This 
more  or  less  popular  notion  is  not  based  upon  the  substantial  facts  of 


130      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

experience.  From  a  physiologic  standpoint  it  would  appear  that  the 
increased  depth  and  frequency  of  the  respirations,  together  with  tlie 
rate  and  vigor  of  the  heart  contractions  incident  to  moderate  altitudes, 
would  produce  an  acceleration  of  blood-flow  and  an  equalization  of  the 
circulation  throughout  the  body.  In  adchtion  to  this  tendencj^  towaixl 
the  avoitlance  of  local  stasis  in  the  lungs  in  appropriate  cases,  recent 
experiments  have  shown  conclusively  that  the  blood-pressure  is  lower 
in  high  altitudes  than  at  sea-level.  The  assumption,  therefore,  seems 
well  founded  that  pulmonary  hemorrhage  in  high  altitudes  should  be 
distinctly  lessened  in  cases  judiciously  selected  with  reference  to  other 
considerations.  My  own  experience  in  Colorado  is  quite  in  keeping 
with  this  ^^ew.  Onl}'  one-fourth  of  the  cases  to  which  allusion  has 
previousl}-  been  made  have  experienced  a  recurrence  of  their  pulmonary 
hemorrhages  subsequent  to  arrival  in  Colorado.  Quoting  from  my 
analysis  of  hemorrhages  in  Colorado:  "  It  is  further  of  interest  to  know 
that  of  the  97  recurrences,  .34  were  in  inchviduals  who  had  experienced 
a  hemorrhage  within  two  weeks  before  arrival,  and  in  whom  it  is  reason- 
able to  suppose  the  direct  results  hail  not  been  fidly  overcome.  In 
fact,  nearly  half  of  these  had  their  hemorrhage  on  the  train  or  immetU- 
ately  prior  to  leaving  home.  Twenty-two  of  the  recurrent  hemorrhages 
in  Colorado  were  exhibited  by  people  in  whom  the  bleetUng  not  only 
took  place  shortly  before  arrival,  but  the  recurrence  within  a  verj-  few 
days  thereafter.  It  is  obvious  that  such  cases  should  not  be  embraced 
in  the  category  of  '  hemorrhages  in  Colorado, '  as  the  specific  cause  was 
put  in  (>ii(M:itinii  liefore  arrival.  Should  these  be  excluded,  and  rightly 
so,  the  |MTriiii:i'_:c  of  recurrences  would  be  materially  diminished.  On 
the  other  haiiil.  47  cases  were  found  to  have  bled  more  or  less  profusely 
within  one  or  two  weeks  before  arrival,  yet  have  never  suffered  a  return 
since  residing  in  the  higher  altitude.  Seventy-one  patients  experienced 
their  first  hemorrhage  after  coming  to  Colorado.  Forty  of  these 
exhibited  very  extensive  advanced  infection,  presenting  such  conchtions 
as  would  be  likely  to  occasion  hemorrhage  anywhere.  Of  the  31  which 
took  place  in  the  midst  of  a  general  gain,  a  large  proportion  resulted 
from  a  distinct  assignable  cause."  My  experience  during  the  six  years 
subsequent  to  the  compilation  of  these  statistics  parallels  closely  the 
analytic  results  previously  obtained. 

Hemorrhages  per  se  constitute  neither  an  indication  nor  a  con- 
trainchcation  for  high  altitudes.  The  choice  of  climate  should  be  made 
with  reference  to  all  the  several  phases  and  conditions,  without  special 
attention  to  hemorrhage  itself.  A  small  proportion  of  recurrences 
may  be  expected  in  moderate  altitudes,  and  this  number  may  be 
diminished  still  more  by  the  institution  of  proper  .supervisory  control. 
Recurrences  are  more  prone  to  ensue  in  those  patients  who  bled  from 
the  lungs  shortly  before  arrival,  in  which  event  tlie  subsequent  hemor- 
rhages are  likel}'  to  take  place  during  the  first  few  days  of  residence  in 
higher  altitudes.  Primary  hemorrhages  are  comparatively  rare  in 
moderate  altitudes,  and,  as  a  rule,  occur  in  cases  with  active  and  exten- 
sive excavation  or  as  a  result  of  some  palpable  indiscretion.  While 
hemorrhages  are  less  apt  to  take  place  in  higher  altitudes  than  at 
sea-level,  thej'  are,  however,  decidedly  more  severe  and  associated 
with  greater  shock.  Hemorrhages  occurring  in  Colorado  do  not,  as 
a  rule,  conform  to  the  benign  t3^pe  so  often  observed  at  sea-level. 


SYMPTOMS    REFERABLE    TO    THE    DIGESTIVE    APPARATUS 


CHAPTER   XXIII 

SYMPTOMS  REFERABLE  TO  THE  DIGESTIVE 
APPARATUS 

Disturbances  in  the  alimentary  tract  may  relate  either  to  the 
stomach  or  to  the  intestine. 

STOMACH  SYMPTOMS 

Gastric  disturbances  are  by  no  means  common  to  all  eases  of  pulmo- 
nary tuberculosis.  A  large  number  of  patients  are  able  to  take  pro- 
digious quantities  of  food  and  digest  it  with  apparent  ease.  An  excellent 
appetite  with  ability  to  digest  food  is  sometimes  noted  to  an  astonishing 
degree,  even  in  advanced  cases,  notwithstanding  the  presence  of  fever 
and  extensive  pathologic  change.  On  the  other  hand,  there  is  a  large 
class  of  patients  who  exhibit  disorders  of  digestion  with  confii'med  loss 
of  appetite  in  the  very  early  stages  of  consumption,  or  long  before  the 
development  of  the  disease.  In  such  cases  the  gastric  symptoms  are 
exceedingly  apt  to  pcrsi-^t  tlndimhout  the  entire  course.  In  another 
class  of  patients  the  st(nn:iili  di-tiirbances  are  of  temporary  duration, 
though  subject  to  frequent  iccuiicnces  by  virtue  of  fever,  nervous  excite- 
ment, general  exhaustion,  and  indiscretions  of  diet.  As  a  matter  of 
fact,  it  is  worthy  of  comment  that  the  functional  power  of  the  digestive 
organs  is  not  impaiised  more  frequently  and  seriously  by  reason  of  these 
causes.  This  is  all  the  more  remarkable  in  view  of  the  lack  of  exerci.se, 
the  toxemia,  malnutrition,  and  coexistence  of  psychoneuroses.  The 
constancy  and  severity  of  the  gastric  symptoms  are  entirely  independent 
of  the  extent  of  pulmonary  lesions.  Generally  speaking,  the  indiges- 
tion is  more  apparent  and  obstinate  in  the  presence  of  continued  eleva- 
tions of  temperature,  general  weakness,  and  functional  nervous  dis- 
turbances. In  very  iii:my  cases,  iianiriijarl}-  of  the  neurotic  type,  it 
is  known  that  an  actual  structmal  chaimi^  in  ihe  digestive  apparatus  is 
not  essential  for  the  production  (if  llie  \aii(ius  symptoms  of  functional 
derangement.  It  is  of  further  interest  to  note  that  severe  dyspeptic 
manifestations  often  occur  in  the  presence  of  normal  gastric  secretions. 
A  predominating  effect,  then,  may  be  ascribed  in  many  patients  to  the 
depraved  nutrition,  the  anemia,  the  nostalgia,  and  the  enforced  quiet. 
In  addition  to  these  influences,  the  profound  psychoneurotic  condition 
so  common  among  pulmonary  invalids  is  an  etiologic  factor  of  especial 
importance.  Often  this  functional  liei'aimcinent  is  responsible  for  a 
picturesque  display  of  clinical  manifesiatimis.  The  symptoms  referable 
to  the  stomach  partake  essentialh'  of  ihe  nature  of  sensory  neuroses, 
neurasthenic  consumptives  being  notoriou.sly  introspective  and  hypo- 
chondriacal. Various  causes  may  operate  in  individual  cases  toward 
the  production  of  gastric  disturbance.  The  organic  changes  sometimes 
relate  to  a  preexisting  chronic  catarrh  of  the  stomach,  the  mucosa  being 
the  site  of  passive  congestion  incident  to  coexisting  cardiac  or  renal 
complication.  Occasionally,  the  results  of  dilatation  and  enteroptosis 
lend  additional  color  to  the  dyspeptic  picture.  Ulceration  and  tui)ercle 
deposit  in  the  stomach  are  comparatively  rare.     In  the  absence  of  patho- 


132      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

logic  change  in  the  abdominal  viscera  the  disturbed  digestion  may  be 
attributable  in  some  cases  to  recognized  abnormality  of  the  stomach 
secretions.  A  frequent  deviation  from  the  normal,  as  determined  by 
gastric  analysis,  is  the  existence  of  hypochlorhydria  in  advanced  stages. 
Irrespective  of  fever,  the  hydrochloric  acid  may  be  reduced  in  amount 
or  absent  altogether  at  any  period  of  the  disease,  although,  as  a  rule, 
in  early  phthisis  this  constituent  of  the  gastric  secretion  is  normal  in 
amount.  In  later  stages  there  is  found  in  many  cases  a  pronounced 
diminution. 

Independent  of  the  precise  quantity  of  hydrochloric  acid,  hyper- 
aciditj-  of  the  stomach-contents  is  frequently  due  to  an  excess  of  the 
organic  acids.  The  gastric  indigestion,  especially  if  developing  late 
in  the  disease,  is  sometimes  but  an  expression  of  the  general  exhaustion. 
At  such  times  there  is  a  lack  of  muscular  tone  to  the  stomach,  with 
resulting   motor   insufficiency. 

Acute  indigestion  following  indiscretions  of  chet  is  often  charac- 
terized by  nau.sea,  with  or  without  vomiting,  anorexia,  bad  taste  in 
the  mouth,  furred  tongue,  offen.sive  breath,  headache,  constipation, 
aiatl  sometimes  pain  in  the  epigastric  region.  Slight  jaundice  may  be 
an  accompanying  symptom. 

Patients  suffering  from  chronic  catarrh  of  the  stomach  experience 
loss  of  appetite,  occasional  loathing  for  food,  coated  tongue,  occasional 
vomiting,  tenderness  upon  pressure  over  the  region  of  the  stomach, 
and  a  constipated  habit,  with  almost  constant  diminution  of  hydro- 
chloric acid. 

When  the  gastric  indigestion  exists  as  a  concomitant  manifestation 
of  general  exhaustion  or  profound  neurasthenia,  there  is  often  an  entire 
lack  of  desire  for  food  of  any  kind,  the  very  idea  of  eating  producing 
extreme  chsgust.  In  some  of  these  cases  actual  hunger  is  described, 
until  the  process  of  ingestion  is  begun.  Upon  endeavoring  to  partake 
of  a  slight  amount  of  food,  such  patients  complain  of  the  utter  impossi- 
bility of  the  task,  some  describing  an  imaginary  obstruction  in  the 
esophagus.  A  characteristic  symptom  is  the  abrupt  onset  of  vomiting 
shortly  after  food  is  consumed,  or  even  before  the  meal  is  finished.  This 
is  particularly  true  of  the  evening  repast,  and  perhaps  is  explainable  in 
part  by  the  increased  temperature  elevation  at  this  time.  The  vomiting 
occurs  without  any  ostensible  cause,  and  is  not  to  be  confounded  with 
the  retching  and  loss  of  food  incident  to  paroxysmal  cough.  In  the 
latter  case  the  vomiting  is  not  dependent  upon  a  digestive  disturbance, 
but  is  referable  entirely  to  the  influence  of  the  cough  itself.  In  both 
instances,  however,  the  vomiting  is  of  purelv  reflex  origin,  the  presence 
of  food  in  the  stomach,  eructation  of  gas.  or  cough  acting  as  exciting 
causes.  The  popular  appellation  of  "stomach  cough,"  applied  to  such 
cases,  is,  of  course,  an  unfortunate  misnomer,  although  it  has  been  recog- 
nized that  a  hearty  meal  ma}-  serve  to  excite  cough. 

Patients  sufTering  from  neurasthenia  frequently  exhibit  other 
symptoms  of  ga.stric  disturbance  of  such  a  character  as  to  justify  their 
classification  under  the  head  of  "nervous  dyspepsia."  With  such 
patients  the  process  of  digestion  is  not  always  retarded  to  any  extent 
in  spite  of  the  presence  of  .symptoms  suggestive  of  serious  impair- 
ment of  stomach  function.  The  most  conspicuous  symptoms  relate 
to  pain  in  the  epigastric  region,  nausea,  pyrosis,  and  frequent  loud 
eructations  of  gas.     The  latter  usually  take  place  when  the  stomach 


SYMPTOMS    REFERABLE    TO    THE    DIGESTIVE    APPARATUS  133 

is  empty,  and  disappear  for  a  short  time  following  the  consumption  of 
food.  The  abdominal  distress  frequently  occurs  independently  of  the 
ingestion  of  food.  There  is  often  a  decided  sensation  of  fulness  in  the 
stomach,  associated  with  perceptible  chstention.  The  tongue  some- 
times is  red  instead  of  coated,  and  the  breath  inoffensive.  Anorexia 
may  be  extreme,  but  vomiting  is  not  an  invariable  feature.  Constipa- 
tion is  usually  the  habit  of  the  individual. 

INTESTINAL  SYMPTOMS 

Disturbances  of  digestion  originating  in  the  intestine  constitute 
an  important  feature  of  pulmonary  tuberculosis.  The  condition  of  the 
bowels  is  of  the  utmost  consequence,  and  not  infrequently  furnishes 
a  sufficient  basis  for  rendering  an  unfavorable  prognosis.  The  intestinal 
derangement  of  chief  importance  is  diarrhea.  This  may  develop  early 
or  late  in  the  disease,  lie  temporary  in  duration,  exist  for  months,  or 
persist  throughout  the  cntiic  course.  It  may  occur  without  other 
symptomatic  manifestaiimis.  and  in  the  presence  of  comparativelj' slight 
pathologic  change  in  the  pulnidiuiry  tissue,  or  it  may  be  absent  in  the 
midst  of  extensive  tuberculous  involvement.  Both  the  character  and 
extent  of  the  diarrhea  vary  within  wide  limits.  There  may  be  but  a 
few  movements  of  the  bowels,  and  these  restricted  to  the  earlj'  morning 
hours,  or  there  may  be  six  or  eight  watery  evacuations  diiiiui;  ilic  day. 
In  the  former  case  the  desire  to  empty  the  bowels  imni((liaiil\  iijion 
awakening  is  imperative,  although  sleep,  as  a  rule,  has  not  liccn  (hs- 
turbed.  After  one  or  two  later  operations,  wliicli  nsnally  take  phice 
after  breakfast,  the  patient  complains  of  no  furthci-  inconxcnirncc  duiiiig 
the  day.  The  dejections  in  such  cases  are  attended  with  but  little,  if 
any,  physical  discomfort,  are  almost  invariably  liquid,  but  rarely 
"watery,"  and  seldom  contain  mucus  or  blood,  although  often  very 
offensive. 

Patients  in  whom  the  intestinal  disturbance  is  more  severe  are 
frequently  awakened  during  the  night  and  at  a  very  early  hour  in  the 
morning.  The  discharges  are  uniformly  described  as  watery  in  char- 
acter, but  in  reality  are  of  a  thin,  soupy  consistencj%  and  sometimes 
contain  I)1(»mI  and  siireds  of  mucus.  As  a  rule,  the  movements  become 
less  copious  as  the  day  advances.  Intestinal  flatulence  is  sometimes 
an  annoying  feature.  When  the  diarrheal  dejections  exceed  three  or 
four  in  number  during  the  twenty-four  hours,  there  is  frequently  con- 
siderable griping  colicky  pain. 

Diarrhea  may  appear  as  a  most  distressing  symptom,  even  in  the 
midst  of  general  improvement,  and  affords  no  criterion  by  which  to 
judge  as  to  the  degree  of  activity  of  the  pulmonary  infection.  It  is  a 
common  erior  to  regard  a  persisting  diarrhea  as  invariably  dependent 
upon  a,  tulieicle  ileposit  in  the  intestine.  Further,  the  demonstration 
of  tubercle  bacilli  in  the  discharges  does  not  always  afford  conclusive 
evidence  that  the  conchtion  is  iiecessaiily  hopeless.  In  a  large  pro- 
portion of  the  diarrheas  of  consuni])tives  it  is  impossible  to  conclude 
definitely  that  the  local  condition  is  tuberculous  in  character.  It  is 
easy  to  theorize  upon  the  possible  dc\cl;ipnieiil  of  an  intestinal  infec- 
tion from  the  swallowing  of  sputum  laden  willi  Inlieirle  bacilli.  This 
undoubtedly  takes  place  in  numerous  instances,  but  i'lini<al  experience 
often  fails  to  disclo.se  either  the  actual  existence  or  incurability  of  such 
lesions. 


134      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

Considering  the  wide  dissemination  of  educational  literature,  it  is 
hard  to  realize  that  any  but  the  densely  ignoi'ant  can  be  guilty  of 
swallowing  their  sputum.  From  my  own  observation  I  am  led  to 
believe  that  this  is  a  rare  occurrence,  possibh^  taking  place  among  insane 
patients  or  those  so  exhausted  by  disease  as  to  blunt  their  sensibilities 
and  obliterate  any  appreciation  of  the  proprieties  and  decencies  of  life. 
I  am  convinced  that  the  swallowing  of  expectoration,  save  in  little 
children,  is  far  less  frequent  than  commonly  believed.  Assuming, 
however,  that  in  some  cases  bacilli-laden  sputum  finds  its  way  into 
the  alimentary  tract,  it  must  be  borne  in  mind  that  the  microorgan- 
isms are  surrounded  to  a  certain  extent  by  a  protective  coating  of 
mucus,  and  diluted  more  or  less  by  the  stomach  and  intestinal  contents. 
In  a  very  considerable  number  of  cases  the  diarrhea  must  be  attrib- 
uted to  some  other  cause  than  intestinal  tuberculosis. 

Continued  looseness  of  the  bowels  is  occasionally  observed  among 
invalids  who  have  never  experienced  any  cough  or  expectoration  what- 
ever. Perhaps  this  very  fact  is  of  value  in  explaining  the  possibility 
of  an  irritation  of  the  nerve  terminals,  with  resulting  increased  per- 
istalsis, from  an  absorption  of  the  toxins  incident  to  the  pulmonary 
infection.  The  production  of  diarrhea  by  the  injection  of  large  doses 
of  tuberculin  is  sngnpstive  of  the  correctness  of  such  conclusions.  It  is 
possible  that  tlic  swallowing  of  sputum,  save  in  young  children,  is  less 
responsible  fm  the  diarrhea  of  consumption  than  has  been  asserted. 
A  pronounced  and  continuous  looseness  of  the  bowels  furnishes  per  se 
no  positive  evidence  of  tuberculous  lesions  within  the  gut,  although 
suspicion  is  at  once  aroused  as  to  the  possible  nature  of  the  afTection. 
This  is  strengthened  by  the  presence  of  blood  and  mucus,  even  in  small 
amounts,  in  the  rectal  discharges,  but  the  recognition  of  tubercle  bacilli 
constitutes  the  only  means  by  which  definitely  accurate  conclusions 
may  be  attained. 

A  diagnosis  of  intestinal  tuberculosis  does  not  necessarily  imply  a 
hopeless  prognosis,  despite  a  poor  general  condition  and  an  active 
involvement  of  the  lung.  During  the  past  few  years  I  have  been 
privileged  to  witness  surprising  improvement  in  .several  patients  of 
this  class  who  were  regarded  as  hopeless  by  virtue  of  every  considera- 
tion which  would  ordinarily  influence  prognosis.  I  am  attending  a 
lady  who,  two  years  ago,  exhibited  distressing  symptoms  of  intestinal 
tuberculosis,  with  accompanying  exhaustion,  fever,  and  the  physical 
signs  of  advancing  cavity  formation.  The  pulmonary  infection  had 
been  of  several  years'  duration,  and  the  intestinal  disturbance  had 
persisted  during  a  period  of  over  six  months.  There  were  from  six 
to  ten  movements  of  the  bowels  daily,  containing  small  quantities  of 
blood  and  mucus.  With  inipiovciiiciu  in  tlio  uoiipral  condition,  disap- 
pearance of  fever,  and  lessened  .■icti\ii\'  of  tln'  imhnonary  process  there 
gradually  took  place  an  anielicnation  of  the  diarrhea,  and  for  the  past 
eight  months  the  bowel  discharges  have  been  entirely  normal. 

A  young  man  of  twenty-five,  a  mechcal  student,  with  moderate 
pulmonary  involvement,  developed  quite  suddenly  a  diarrhea  which 
persisted  for  several  weeks.  This  was  associated  with  rapid  loss  of 
flesh  and  strength  and  moderate  elevation  of  temperature.  Tliere  was 
no  blood  or  mucus  in  the  discharges,  but  bacilli  were  readily  found 
upon  examination.  The  patient  was  put  to  bed  and  a  rigid  diet,  with 
appropriate   medication,  instituted.     After  some  weeks  he  was   per- 


SYMPTOMS    REFERABLE    TO    THE    MIND    AND    NERVOUS    SYSTEM       135 

mitted  to  remain  upon  the  porch  a  portion  of  each  day.  This  method 
of  management  was  maintained  for  over  a  year,  until  the  movements 
became  perfectly  normal  in  number  and  appearance  and  repeated 
examinations  disclosed  no  bacilli.  In  the  mean  time  there  has  taken 
place  an  entire  arrest  of  the  pulmonary  infection. 

I  have  in  mind  three  other  cases  now  under  observation  which  also 
illustrate  the  possibility  of  improvement  in  cases  of  this  character.  As 
a  rule,  however,  intestinal  tuberculosis  occurring  in  advanced  stages  of 
consumption  must  be  regarded  as  a  most  ominous  complication.  The 
tuberculous  lesions  may  affect  any  part  of  the  intestinal  tract,  l)ut  the 
region  of  the  cecum  is  more  frequently  involved.  There  is  often 
definite  ulceration,  the  ulcers  being  irregular,  round  or  o\()i(l  in  con- 
tour. Extensive  hyperplastic  change  sometimes  takes  place.  Intestinal 
tuberculosis  will  be  discussed  more  fully  under  Complications. 


CHAPTER   XXIV 


SYMPTOMS  REFERABLE  TO  THE  MIND  AND  NERVOUS 
SYSTEM 

Considerable  interest  attaches  to  the  mental  condition  of  the  pulmo- 
nary invalid.  Deviations  from  a  normal  mental  status  are  ascribed 
to  many  consumptives,  who  are  often  spoken  of  as  irritable,  unreason- 
able, selfish,  or  cranky.  An  effort  has  been  made  to  group  the  mental 
attributes  of  tuberculous  individuals  in  such  a  manner  as  to  permit 
their  classification  according  to  distinct  types.  Many  so-called  charac- 
teristics of  the  consumptive  have  been  supposed  to  develop  as  a  direct 
result  of  the  pulmonary  affection.  Some  of  these  peculiarities  of  tem- 
perament are  thought  to  obtain  particularly  during  the  early  period  of 
pulmonary  tuberculosis,  and  to  be  replaced  later  by  widely  differing 
manifestations. 

Such  notions,  entertained  with  reference  to  essential  traits  of  charac- 
ter common  to  this  class  of  invalids,  are  largely  iiiconcci .  I'linda- 
mentally  distorted  views  have  been  accepted  as  to  the  rchitidii  existing 
between  the  underlying  disease  and  the  various  forms  of  nicnlal  or 
nervous  disturbance.  The  central  thought  to  be  biniic  in  mind  in 
this  connection  is  the  fact  that  it  is  not  the  pulmonary  inlfciion  which 
serves  to  modify  character,  liut  rather  the  inherent  peculiarities  of 
temperament  which  tend  to  influence  materially  the  clinical  course 
and  prognosis  of  consumption.  Generally  speaking,  those  individuals 
who  are  depressed,  melancholic,  and  pessimistic  before  the  onset  of 
tuberculosis  will  exhibit  the  same  distinctive  tendencies  subsequent  to 
its  development.  Those  who  are  sanguine,  optimistic,  and  of  an  expan- 
sive turn  of  mind  will  remain  unchanged.  The  densely  ignorant  and 
obstinate  cannot  be  transformed  through  the  advent  of  a  condition 
entailing  suffering  and  disappointment.  Those  who  are  irritable, 
wilful,  and  unrestrained  cannot  fail  to  stamp  the  impress  of  their  unfortu- 
nate nervous  infirmities  upon  the  clinical  picture.     The  vital  point  is  the 


136      SYMPTOMATOLOGY    AND    COURSE.    VARIETIES    AND    TERMINATION 

thought  that  it  is  not  the  disease  itself,  but  rather  the  individual, 
offering  the  greater  field  for  study  and  attention. 

The  practical  consideration  relates  to  the  extent  to  which  the  pre- 
vious mental  status  is  actually  altered  either  cUrectly  or  indirectly  as 
a  result  of  pulmonary  tuberculosis.  It  is  entirely  natural  to  expect 
some  temperamental  change  by  reason  of  the  physical  restraint  and 
mental  disquietude  incident  to  the  invalidism  and  the  environment. 
It  is  contended,  however,  that  such  changes  are  not  sufficiently  constant 
or  uniform  in  their  nature  to  justify  a  general  classification.  It  is  futile 
to  attemjit  any  definite  generalization  with  reference  to  the  mental 
attitude  of  the  consumptive,  and  the  larger  one's  experience,  the  less 
likelihood  of  indulging  in  such  an  effort.  In  advanced  cases  indi\adual 
modifications  of  disposition  may  easily  take  place  as  a  result  of  the  general 
weakness,  precisel}^  as  in  other  exhausting  diseases.  With  many  patients 
exhibiting  evidences  of  profound  toxemia  the  mental  or  nervous  equi- 
librium is  rendered  still  more  unstable.  Less  advanced  consumptives  are 
inevitably  influenced  to  some  extent  by  their  markedly  altered  conditions, 
their  immediate  surroundings,  and  pro.spects  for  the  future.  The  knowl- 
edge of  their  ]>h>-si(al  state,  the  separation  from  home,  the  life  of  indo- 
lence, the  ali-iiKc  111  hiuli  ideals,  the  lack  of  healthful  occupation  of 
the  mind,  the  a-sniiatioii  with  othei's  .similarly  afflicted,  and  in  some 
instances  the  interminable  duration  of  the  illness,  must  motlify  to  some 
extent  their  natural  characteristics.  By  virtue  of  these  causes  some 
invalids  may  exhibit  a  certain  accentuation  of  their  inherent  peculiari- 
ties; others  may  cUsplay  a  slight  perversion  of  former  proclivities,  and 
a  few  may  disclose  acquired  degenerative  tendencies.  It  has  been 
stated  comparatively  recently  by  various  writers  that  consumptives, 
through  the  very  nature  of  their  disease,  become  more  or  less  perverted 
nervously,  cultivating  habits  of  self-indulgence,  loss  of  self-control  or 
moral  restraint,  developing  an  inability  to  appreciate  the  proportionate 
fitness  of  things  and  exhihitinsr  tlie  stigmata  of  varying  degrees  of 
degeneration.  WhUe  such  broad  !:cueralizations  are  quite  unwarranted, 
the  fact  remains  that  consuni]itives,  like  other  individuals,  are  neces- 
sarily creatures  of  their  environment.  From  my  own  observation,  the 
most  frequent  resultant  of  the  various  component  factors  is  the  develop- 
ment of  a  remarkable  adaptation  of  the  individual  to  new  surroundings 
and  a  philosophic  acceptance  of  the  radically  changed  status  in  life. 
An  admirable  resignation  is  more  often  exhibited  than  a  rebellious 
disposition.  Unwillingness  to  conform  to  the  implacable  necessities 
of  phy.sical  disability  is,  indeed,  unusual.  Following  the  shock  of  the 
initial  information  as  to  the  character  of  the  disease,  the  attitude  of  the 
average  consumptive,  despite  an  intelligent  conception  of  the  grave 
possibilities,  is  that  of  unflinching  courage.  Notwithstanding  the 
doubtfulness  of  the  issue,  the  immediate  future  is  often  contemplated 
with  philosophic  acceptance.  In  most  instances  there  is  exhibited  a 
lingering  and  abiding  hope,  rather  than  actual  faith,  in  a  favorable 
outcome.  This  intention  .to  meet  with  fortitude  what  may  be  held  in 
store  should  not  be  described  as  a  form  of  optimism  or  of  pessimism. 
Either  of  these  may  be  present  in  individual  cases,  but  such  does  not 
typify  the  mental  condition  of  pulmonary  invalids  as  a  class. 

The  optimism,  which  so  often  has  been  stated  to  characterize  the 
attitude  of  the  consumptive  even  in  the  last  hours,  is  usually  founded 
upon  ignorance  of  the  impending  danger.     This  results  either  through 


SYMPTOMS    REFERABLK    TO    THE    MIND    AND    NERVOUS    SYSTEM       137 

misrepresentation  by  the  physician  and  family,  or  on  account  of  an 
utter  inability  of  the  patient  to  comprehend  statements  that  have  been 
made. 

Pessimism,  when  present,  is  not,  as  a  rule,  the  result  of  long-con- 
tinued and  unavailing  efforts  toward  securing  arrest  in  the  sense  that 
"hope  deferred  maketh  the  heart  sick,"  but  rather  is  an  outward  expres- 
sion of  the  mental  makeup  of  the  individual.  After  years  of  fruitless 
endeavor  to  promote  recovery  the  attitude  of  the  patient  usually 
becomes  that  of  stoical  indifference  rather  than  of  pessimism,  depression 
of  spirits,  or  melancholia.  These  latter  attributes  were  of  earlier  for- 
mation, and  usually  entered  into  the  character  of  the  patient  previous 
to  the  disease.  Temporary  periods  of  depression  from  minor  causes 
are  fairly  common,  perhaps  characterizing  a  larger  number  of  pulmonary 
invalids  than  the  exaltation  of  spirits  which  is  sometimes  attributed 
to  them.  Moderately  increased  irritalulity  of  temperament  is  not 
infrequent,  and  is  accompanied  by  a  tendency  to  worry  over  trifles. 
Often  the.se  are  ma^nificil  to  such  an  extent  as  to  assume  undue  propor- 
tions in  comparison  with  ^•ital  considerations  to  which  little  importance 
is  attached.  The  inaljility  to  appreciate  fully  a  due  sense  of  propor- 
tion which  is  occasionally  displayed  in  individual  instances  may  be 
described  as  a  lack  of  critical  faculty  obtaining  among  consumptives 
in  general.  Some  become  less  cheerful,  are  especially  susceptible  to 
annoyance,  and  quick  to  take  offense.  There  ai-e  often  exhibited  im- 
pulsiveness, emotional  weakness,  and  astonishing  fickleness  of  mood. 
The  changes  from  dcs]);iii-  to  cxiiliciancc  of  feeling  and  vice  versa  are 
striking  and  kaleidosc(i|iic.  'I'hc  .-ilx-iicc  of  self-control  is  one  of  the 
more  important  feature.-,  Ii),uclli(-r  with  ;i  certain  dependence  upon  others 
and  lack  of  aggressive  initiative,  l^ochiction  of  will  power  and  inability 
to  think  strongly  and  consecutively  are  sometimes  oljserved.  A  few, 
as  a  result  of  their  long-continued  habits  of  idleness,  with  perhaps  pre- 
vious non-existence  of  high  incentives,  become  utterly  devoid  of  ambition 
and  degenerate  into  a  state  of  gossipy  incompetence.  From  my  per- 
sonal observation,  however,  I  can  assert  with  emphasis  that  a  large 
number  of  pulmonary  invalids,  as  a  direct  result  of  their  own  suffering, 
both  mental  and  physical,  and  intimate  contact  with  misfortune  and 
misery  in  others,  are  led  to  a  life  of  greater  sympathy  and  broader 
charity. 

PERVERTED  MENTALITY 

In  addition  to  the  frequent  exaggeration  of  previous  temperamental 
tendencies  among  pulmonary  invalids,  the  functional  nervous  disturb- 
ances may  be  of  such  a  character  as  to  constitute  a  distinctly  perverted 
cerebration.  These  morbid  psychologic  states  aic  usually  not  sufficient 
in  degree  to  justify  their  classification  inidci'  the  heading  of  insanity. 
The  evidences  of  a  disturbed  mental  e<|iuliliiiuiii  may  consist  merely  of 
a  definite  suspicion  of  men  and  things.  Usually  this  is  associated  with 
a  gloomy  disposition,  surly  manner,  and  a  pronounced  skeptical  or 
pessimistic  attitude.  Such  patients  are  quick  to  take  offense  over 
imaginary  grievances,  readily  become  perversely  argumentative,  are  apt 
to  attach  an  erroneous  significance  to  the  tenor  of  one's  remarks,  miscon- 
strue motives,  develop  implacable  animosities,  and  cherish  vindictive 
tendencies. 

Fixed  delusions  are  rarely  ob.served  in  the  course  of  consumption. 


138      SYMPTOMATOLOGY    AXD    COURSE.    VARIETIES    AND    TERMINATION 

Monomania,  when  present,  is  almost  always  an  expression  of  a  previous 
disturbed  mental  condition,  and  is  largely  independent  of  the  pulmonary 
disease.  It  may  be  intensified  to  a  degree  by  tlie  exhaustion,  inanition, 
toxemia,  and  psychic  conditions  incident  to  the  tuberculous  infection. 
The  paranoia  may  have  been  previously  latent  in  some  cases,  and  subse- 
quently become  a  prominent  and  discomforting  feature,  through  the 
immediate  influence  of  severe  intercurring  complications.  I  have  seen 
delusions  make  their  appearance  shortly  after  the  onset  of  a  severe  pul- 
monary hemorrhage  and  pneumothorax.  In  fact,  in  a  few  exceptional 
cases  a  complete  transformation  of  the  disposition  and  character  of  the 
patient  has  followed  these  two  unfortunate  occurrences. 

The  delusions  which  are  observed  in  connection  with  hemorrhage 
and  pneumothorax  do  not  always  become  apparent  until  after  the 
acutely  grave  symptoms  incident  to  the  complication  have  subsided. 
The  delayed  delusions  which  I  have  observed  imder  such  circumstances 
have  been  almost  invariably  of  an  unpleasant  character.  Thej'  usually 
have  been  associated  with  the  sudden  adoption  of  a  sullen,  irritable,  and 
morose  disposition,  with  a  distinct  tendency  to  gloomy  forebodings. 

Hallucinations  may  be  present  during  short  periods  as  a  result  of 
meningeal  tuberculo.sis,  extreme  general  debility,  or  marked  hysteria. 
They  also  may  occur  after  an  abrupt  elevation  of  temperature  from  any 
cause,  in  the  midst  of  intense  phy.sical  suffering  incident  to  pneumo- 
thorax or  severe  pulmonary  hemorrhage,  during  the  course  of  broncho- 
pneumonia, and  particularly  in  patients  who  have  been  adchcted  to 
undue  alcoholic  stimulation.  Delusions,  hallucinations,  and  even  com- 
plete temporary  insanitj'  occasionally  attend  functional  disturbances 
accompanied  by  intense  pain  in  females.  There  is  a  lady  now  under 
my  care  who  is  subject  to  such  disturbances  at  intervals.  She  recently 
exhibited,  during  a  period  of  twelve  hours,  coincident  with  a  severe 
migraine,  dilatation  of  one  pupil,  inability  to  protrude  the  tongue,  dif- 
ficulty in  articulation,  paralysis  of  one  side  of  the  face,  one  arm,  and 
one  leg,  and  entire  absence  of  normal  cerebration. 

Delusions  and  recurring  hallucinations  developing  suddenly  during 
the  course  of  pulmonary  tuberculosis  and  not  occurring  as  terminal 
symptoms  are  often  but  temporary  in  duration.  A  proper  environment, 
with  painstaking  detailed  management,  increased  nutrition,  and,  above 
all,  the  judicious  employment  of  opium,  are  usually  sufficient  to  restore 
the  patient  to  a  normal  mental  condition. 

The  reestablishment  of  the  former  mental  state  may  be  expected  to 
correspond  to  a  degree  with  the  manifestations  of  general  improvement. 
In  the  midst  of  a  continued  general  decline  initiatory  mild  delusions 
are  sometimes  replaced  by  an  active  delirium  which  persists  for  months. 
I  have  seen  distinct  maniacal  symptoms  with  ravang  delirium  continue 
for  two  months  in  a  patient  who  had  suffered  an  intercurring  pneumo- 
thorax. 

Insanity  with  suicidal  mania  is  not  uncommon  as  a  final  result  of 
the  profound  depression  and  melancholia  occasionally  witnessed  in  pul- 
monary invaliils.  I  have  observed  three  cases  of  suicide  among  my 
patients  in  whom  the  melancholia  had  been  of  comparatively  short 
duration,  even  developing  in  the  midst  of  general  improvement.  Some- 
what analogous  is  the  case  of  a  lady,  thirty-five  years  of  age.  who  devel- 
oped complete  functional  insanity  notwithstanding  an  increased  nutri- 
tion and  an  entire  arrest  of  the  tuberculous  process.     Her  condition 


SYMPTOMS    REFERABLE    TO    THE    MIND    AND    NERVOUS    SYSTEM      139 

upon  arrival  in  Colorado  was  that  of  an  active  extensive  tuberculous 
infection  of  each  lung.  There  was  severe  cough,  with  copious  expec- 
toration, great  emaciation,  anorexia,  daily  fever,  pallor,  and  dyspnea. 
After  remaining  in  bed  for  many  months  in  the  open  air  and  displaying 
remarkable  improvement  in  all  respects,  there  became  manifest  a  loss  of 
memory,  great  difficulty  of  speech,  inability  to  articulate,  lack  of  com- 
prehension, and  failure  to  recognize  her  own  family.  There  were  well- 
defined  delusions  of  fear,  the  jjatient  several  times  attempting  to  jump 
from  a  second-story  porch.  Hallucinations  were  frequent.  Although 
there  had  taken  place  a  remarkable  gain  in  weight,  the  nutrition  later 
was  maintained  with  much  difficulty,  as  she  exhibited  a  positive 
unwillingness  to  take  food.  She  endeavored  many  times  to  swallow 
the  contents  of  the  sputum-cup,  and  indulged  in  other  practices  equally 
revolting.  The  condition  was  at  first  regarded  by  the  consultant.  Dr. 
Pershing,  and  myself  as  a  functional  psychosis  incident  to  the  general 
exhaustion,  but  it  was  somewhat  difficult  to  reconcile  this  view  with 
the  fact  that  the  mental  disturbance  developed  during  a  pronounced 
general  improvement.  After  the  insanity  had  persisted  for  fully  three 
months  she  was  sent  home  to  a  lower  altitude  as  hopelessly  insane. 
Within  two  weeks  following  her  return  her  mind  apparently  was  com- 
pletely restored.  After  the  lapse  of  three  years  there  has  been  no  return 
of  her  mental  disturbance  and  no  evidence  of  renewed  activity  of  the 
pulmonary  disease.  The  case  is  reported  simply  because  of  its  anom- 
alous characteristics. 

Evidences  of  a  disturbed  mentality  are  observed  quite  frequently 
toward  the  end  of  the  disease.  There  may  be  delusions,  mild  or  raving 
delirium,  stupor,  and  coma,  in  some  cases  independent  of  the  existence 
of  a  terminal  tuberculous  meningitis.  This  disease  presents  well-defined 
manifestations,  and  will  be  considered  at  some  length  under  the  subject 
of  Complications.  Disturbances  of  the  peripheral  nervous  system, 
consisting  of  hyperesthesia,  paresthesia,  anesthesia,  neuralgia,  and 
other  phenomena  common  to  the  various  forms  of  neuritis,  though 
sometimes  observed  in  consumptives,  are  scarcely  worthy  of  special 
consideration. 

INSOMNIA 

Although  many  consumptives  suffer  from  disturbed  sleep,  insomnia 
is  not  a  constant  feature  of  the  disease,  bears  no  fixed  relation  to  the 
physical  condition  or  other  subjective  manifestations,  and  is  due  only 
in  part  to  the  coexistent  pulmonary  condition.  The  loss  of  sleep  can 
be  traced  in  many  instances  to  preexisting  nervous  disturbances  or 
idiosyncrasies  of  temperament.  The  insomnia  may  precede  consump- 
tion for  many  months  or  years,  and  disappear  entirely  after  the  advent 
of  the  tuberculous  infection  by  virtue  of  a  perfected  system  of  manage- 
ment, and  the  psychic  influence  attending  change  of  surroundings. 
Inability  to  sleep,  therefore,  is  not  immediately  referable  to  the  disease 
which  it  accompanies,  save  in  those  cases  in  which  an  associated  etio- 
logic  factor  can  be  assigned. 

Many  consumptives,  irrespective  of  their  physical  condition,  experi- 
ence but  little  difficulty  in  sleeping.  Rest  may  be  disturbed  slightly 
by  cough,  which  in  some  instances  occurs  immediatel.v  upon  assum- 
ing the  recumbent  posture,  and  then  subsides  for  the  night.  Others 
suffer    no    especial   exacerbation    of    cough    upon    retiring,    but    their 


140      SYMPTOMATOLOGY    AND    COIRSE,    VARIETIp;S    AND    TERMINATION 

subsequent  sleep  is  frequently  disturbed.  Night-sweats  may  be  a 
factor  in  the  production  of  insomnia,  the  patient  reposing  quietly  until 
awakeneel  in  the  midst  of  a  drenching  perspiration.  The  discomfort 
incident  to  this  distressing  symptom  is  usually  such  as  to  preclude  an 
immediate  resumption  of  sleep.  In  many  cases  the  origin  of  the  insom- 
nia is  traceable  to  nervous  excitation  incident  to  external  causes. 
Animated  conversation  late  in  the  evening,  a  controversial  argument, 
exuberance  of  spirits  through  injudicious  social  indulgence,  card-play- 
ing, and  enlivening  music  often  act  as  exciting  causes.  Among  some 
pulmonaiy  invalids  the  sleeplessness,  although  exhibiting  variations  in 
degree,  may  be  more  or  less  continuous  and  constitute  a  clinical  manifes- 
tation of  considerable  importance.  With  other  patients  it  is  of  purely 
temporary  duration.  Comparatively  few  consumptives  suffer  from 
insomnia  as  a  result  of  woriy  over  their  unfortunate  condition.  There 
may  be  sources  of  fleeting  anxietj'  and  disquietude,  but  these  distur- 
bances in  many  instances  are  occasioned  by  trifling  affairs,  as  fancied 
grievances  and  personal  slights,  which  are  often  exaggerated  until  they 
assume  prodigious  proportions.  These  mental  obliquities  are  far  more 
apt  to  cause  nervous  excitation  and  induce  loss  of  sleep  than  is  actual 
fear  regarding  the  future.  The  attitude  of  man}'  patients  when  unruffled 
by  disturbing  trifles  is  apparently  that  of  complacent  acquiescence. 

Among  patients  suffering  from  confirmed  insomnia  regartUess  of  excit- 
ing causes  there  are  some  who  find  it  hard  to  fall  asleep,  but  finally  secure 
their  rest  after  the  lapse  of  several  wakeful  hours.  Others  experience 
no  difficulty  in  going  to  sleep  shortly  after  retiring,  but  invariably 
awaken  a  few  hours  later,  to  toss  and  turn  during  the  remainder  of  the 
night.  It  is  quite  characteristic  of  a  large  class  of  patients  who  are 
troubled  with  insomnia  to  awaken  unreasonably  early  in  the  morning. 
Many  invalids  possess  the  happy  faculty  of  sleeping  during  the  day 
as  well  as  by  night.  Some  of  these  will  average  from  two  to  three 
hours  daily  without  apparently  detracting  from  their  ability  to  enjoy 
peaceful  repose  at  night.  The  favorable  prognostic  import  of  this 
gift  is  almost  inestimable.  With  some  patients  its  attainment  appears 
an  absolute  impossibility. 

Sleep  is  not  infrequently  broken  by  disturbing  dreams.  These  are 
more  likely  to  be  unpleasant  than  otherwise.  In  the  more  advanced 
cases  of  pulmonary  phthisis  the  sleep  may  become  a  heavy  stupor, 
the  patient  remaining  for  hours  in  a  .state  of  semicoma.  Taken  as  a 
whole,  the  insomnia  of  consumptives  depends  largely  upon  the  tem- 
perament and  nervous  state  of  the  invalid,  and  though  influenced  to 
some  extent  by  associated  disturbances,  is  not  inherent  to  the  tubercu- 
lous infection.  In  fact,  when  present,  it  is  more  a  result  of  the  environ- 
ment than  of  the  physical  condition,  and  responds  to  management 
directed  to  the  individual  rather  than  to  the  disease.  The  ability 
to  sleep  is  sometimes  affected  strikingly  by  the  influence  of  climate. 
It  .should  be  borne  in  mind,  however,  that  the  result  is  not  always  to 
be  attributed  to  the  climate  itself,  but  often  to  the  psychic  influ- 
ence and  change  in  environment.  It  has  been  my  observation  that 
prolonged  and  refreshing  sleep  is  more  easy  of  attainment  in  high 
altitudes  than  at  sea-level.  Many  patients,  shortly  after  arrival, 
express  .surprise  and  gratification  at  an  ability  to  sleep  to  an  extent 
previously  unknown.  The  reverse  is  sometimes  true,  though  less 
frequently.     In  some  of  the  latter  cases  suggestion  plays  an  impor- 


SYMPTOMS    REFERABLE    TO    THE    MIND    AND    NERVOUS    SYSTEM      141 

tant  part,  as  the  invalids  are  often  told  before  leaving  home  that 
they  may  experience  difficulty  in  sleeping  at  high  altitudes.  In  1898, 
in  a  paper  entitled  "  Functional  Nervous  Disturbances  in  Pulmonary 
Invalids,"  I  called  attention  to  the  very  frequent  association  of  con- 
sumption with  the  various  forms  of  functional  nervous  disturbances, 
and  from  an  analysis  of  350  cases  endeavored  to  study  the  relation 
existing  between  the  two.  It  was  found  that  in  almost  no  case  were 
the  manifestations  of  nervous  disorder  displayed  for  the  first  time  in 
Colorado.  But  few  suffered  an  aggravation  of  the  nervous  symptoms 
after  arrival,  and  many  of  these  exhibited  a  satisfactory  improvement. 
Some  patients  displayed  a  persisting  insomnia,  and  in  these  cases  the 
gain  was  slow  and  interrupted  by  periods  of  vexatious  exacerbations. 
The  continued  loss  of  sleep  was  found  to  be  of  decidedly  unfavorable 
influence  upon  prognosis,  not  merely  from  the  entailed  exhaustion,  but, 
also,  as  an  expression  of  the  more  profound  nervous  irritability  with 
general  susceptibility  to  all  depressing  or  exciting  influences.  The 
few  who  displayed  increased  nervous  excitation  did  so  coincidently 
with  a  corresponding  loss  in  the  general  condition.  Some  presented 
evidences  of  nervous  disturbance  attributable  directly  to  external 
causes,  which  would  be  operative  in  any  climate,  as  excessive  dissipation, 
extreme  burden  of  business  cares,  and  unfortunate  domestic  relations. 
A  reasonable  interpretation  of  my  analytic  study  at  that  time,  which 
has  been  confirmed  by  subsequent  observation,  suggests  that  the 
influence  of  the  climate  upon  the  nervous  condition  is  especially  advan- 
tageous in  a  large  proportion  of  cases  by  virtue  of  the  increased  nutrition 
and  resulting  general  improvement.  It  can  be  assumed  that  the 
tuberculous  invasion  may  render  more  pronounced  all  preexisting 
nervous  disturbances,  may  increase  individual  susceptibility  to  such 
conditions  in  those  already  predisposed,  and  may  provide  a  greater 
likelihood  for  their  acquired  development  through  the  influence  of 
impaired  nutrition  and  general  exhaustion.  Likewise  the  existence  of 
well-marked  functional  derangement  affords  additional  opportunities  for 
the  extension  of  the  tuberculous  infection  through  the  lessened  resist- 
ance of  the  individual.  Impaired  general  nutrition,  while  often  a  result, 
is  also  a  most  important  factor  in  the  causation,  of  each  diseased  condi- 
tion. It  is  thus  evident  that  the  nervous  disturbance  may  be  expected 
to  diminish  almost  invariably  in  proportion  to  the  degree  of  arrest  of 
the  tuberculous  process  and  the  gain  in  the  general  strength. 

It  has  often  been  asserted  that  the  existence  of  insomnia  and  other 
nervous  manifestations  contraindicates  recourse  to  moderate  or  high 
altitudes  for  the  consumptive.  This  position  is  entirely  in  opposition 
to  the  logic  of  actual  experience  in  such  localities.  Such  statements 
predicate  the  assumption  that  improvement  in  the  functional  dis- 
turbance must  precede  gain  in  the  general  condition.  This  adva.nces 
the  argument  at  the  same  time  that  the  nervous  derangement  is  of 
more  immediate  .significance  than  the  tuberculous  infection.  It  is 
decidedly  more  rational  to  regard  the  tuberculous  involvement  as  the 
factor  of  essential  importance.  Insomnia  and  other  nervous  distur- 
bances in  pulmonary  invalids  indicate  an  especial  necessity  for  strict 
supervision  of  the  details  of  management,  the  environment,  and  mode 
of  life. 


142      SYMPTOMATOLOGY    AXD    COURSE,    VARIETIES    AND    TERMINATION 

NERVOUS  ENERGY 

There  is  a  vast  difference  in  the  degree  to  wliich  pulnaonary  invalids 
retain  their  nervous  energy.  This  does  not  always  vary  in  accordance 
with  their  physical  endurance,  nor  with  the  progress  of  the  pulmonary 
disease.  Sonie  exhibit  an  astonishing  vitality  almost  to  the  very  end, 
although  their  physical  strength  may  be  impaired  very  seriously.  This 
disproportionate  energ>'  may  often  be  observed,  despite  the  existence 
of  considerable  dyspnea,  loss  of  weight,  fever,  and  night-sweats.  It 
must  not  be  assumed  that  the  inordinate  nervous  vigor  of  such  people 
is  due  to  the  influence  of  the  disease  itself.  As  a  matter  of  fact,  it 
exists  in  spite  of  advancing  tuberculosis.  Some  individuals  who  have 
been  endowed  by  nature  with  an  excess  of  nervous  force  retain  a  sur- 
prising degree  of  vital  energy  notwithstanding  the  unceasing  drain 
incident  to  pulmonary  tuberculosis.  It  must  be  admitted  that  in 
many  cases  the  overflow  of  nervous  energy  is  simulated  rather  than 
real," as  some  patients,  in  their  transparent  effort  to  deceive  themselves, 
manifest  an  undisguised  pride  in  their  show  of  apparent  strength. 
Upon  the  other  hand,  many  invalids  early  exhibit  pronounced  nervous 
debility. 

There  is  no  stimulating  effect  upon  the  nervous  system  inherent 
to  pulmonary  tuberculosis.  On  the  contrary,  impairment  of  nervous 
energy  usually  results.  Often  this  precedes  loss  of  physical  capacity, 
and  sometimes  the  appearance  of  symptoms  referable  to  the  tubercidous 
invasion.  Many  patients  complain  of  lassitude,  indisposition,  fatigue, 
loss  of  ambition,  and  extreme  weariness  for  months  before  the  appearance 
of  cough,  fever,  or  other  manifestations  distinctly  suggestive  of  con- 
sumption. They  usually  awaken  in  the  morning  more  or  less  tired, 
having  secured  no  refreshing  invigoration  from  their  sleep.  It  is  an 
effort  for  them  to  get  out  of  bed,  they  do  not  enjoy  work,  their  usual 
vocations  appear  distasteful,  and  minor  obstacles  are  magnified  to  large 
proportions.  They  are  often  unable  to  think  consecutively,  the  power 
of  mental  concentration  being  diminished  to  a  considerable  extent. 
They  frequently  lack  decision  or  will  power,  and  vacillation  is  sometimes 
quite  apparent.  Upon  the  definite  clinical  onset  of  pulmonary  tuber- 
culosis these  evidences  of  impaired  nervous  force  increase  with  the 
advance  of  the  disease.  It  is. not  unusual  to  observe  a  very  manifest 
disinclination  to  go  out-of-doors,  some  invalids  preferring  to  remain 
in  the  house  and  die  comfortably  rather  than  to  make  an  effort  to  secure 
fresh  air. 


CHAPTER  XXV 


SYMPTOMS  REFERABLE  TO  THE  GENITO-URINARY 
TRACT 

Tuberculosis  of  the  genito-urinary  system  will  be  found  discussed 
in  some  detail  under  Complications.  Non-tuberculous  nephritic 
disturbances  are  considered  in  connection  with  Mixed  Infection.  A 
description  of  the  symptoms  of  accompanying  renal  disease,  as  well  as 


SYMPTOMS    REFERABLE    TO    THE    UEXITO-URIXARY    TRACT  ]  43 

those  pertaining  to  tuberculous  infection  of  the  genito-urinary  tract, 
therefore,  will  not  be  detailed  in  this  chapter. 

The  various  forms  of  nephritic  distiu-bance  are  by  no  means  uncom- 
mon in  pulmonary  tuberculosis.  There  often  exist  distinct  degenera- 
tive changes  of  amyloid  character,  acute  and  chronic  involvements  of 
the  parenchyma,  and  the  chronic  interstitial  variety  of  kidney  di.sea.se. 
There  are  frecjuently  no  symptoms  of  the  ciironic  forms  of  nephritis 
until  the  condition  is  far  advanced,  the  cUagnosis  being  secured  only 
through  periodic  examinations  of  the  urine.  Very  often,  in  the  course 
of  routine  examinations,  I  have  found  albumin  in  the  urine  long  before 
the  appearance  of  any  symptom  suggestive  of  the  kidney  involvement. 
Hyaline  and  granular  casts  have  also  been  recognized  in  many  cases, 
sometimes  1ieforo  the  appo:ir:!iico  of  albumin.  Attention  will  be  directed 
in  anothci-  ilui]ilci'  in  ilic  lici|iicnt  detection  of  tubciclr  b;;cilli  in  the 
urine  of  puliiKin.ii  y  iii\  .ilid,.  Animal  experiiiicuuil  ion  li:is  shown 
that  inoculation  with  tlie  urine  of  consumptives,  in  entire  absence  of 
tubercle  bacilli  or  suggestive  clinical  manifestations,  is  followed  in 
many  instances  by  the  death  of  the  animal  from  tuberculous  infection. 
The  symptoms  of  renal  disease  vary,  of  coiu'se.  with  the  n;iture  nnd 
extent  of  the  nephritic  change.  It  is  note\\(irtli\-  Ihnt  sm  h  UKinilcsta- 
tions  as  dyspnea,  increasing  pallor,  dimiuishiiii;  st  rciii^th.  sliiilit  ciliina 
of  the  hands,  face,  or  ankles,  are  commonly  attributed  to  the  pulniunary 
infection,  although  caused  in  many  cases  by  an  unrecognized  involvement 
of  the  kidneys.  There  are  often  pi-esent  digestive  disturbances  as  well  as 
changes  in  the  pulse,  which  may  become  of  high  tension.  While  patients, 
as  a  rule,  may  be  expci-tiMl  id  succuinli  (•(iiii|i:ii:ili\cl>'  mhui  uI'Iit  the 
development  of  marked  itikiI  discusc,  shimc.  incs]iccli\c  dI'  Ihi-  nature 
and  extent  of  the  pathologic  change,  may  lingci-  <hirin,u  a  pi(ilt>iiL;('d 
period  of  time.  I  have  in  mind  a  man,  thirty-four  years  dl  .■me.  a  |iai  lent 
of  Dr.  Hugueley,  of  Atlanta,  Ga.,  who  was  sent  Ikhiic  \n  .lie  Ww  years 
ago  on  account  of  advanced  pulmonary  phthisis  complicated  by  chronic 
nephritis  of  nearly  three  years'  duration.  I  recognized  the  presence  of 
chronic  Bright's  disease  in  August,  1900,  and  was  unable  to  note 
evidence  of  substantial  improvement  at  any  time  during  the  following 
two  years.  In  the  fall  of  1902  there  was  extensive  active  involvement 
of  both  lungs,  with  abundant  excavation  in  each,  and  moderate  cardiac 
hypertrophy.  The  urine  was  invariably  diminished  in  quantity  and  of 
high  specific  gravity.  There  was  an  enormous  amount  of  albumin,  with 
numerous  casts  of  the  hyaline  and  small  granular  varieties,  as  well  as 
occasional  leukocytes  and  blood-cells.  Edema,  cyanosis,  and  dyspnea 
were  marked.  The  patient  shortly  afterward  underwent  a  double 
renal  decapsulation  in  the  hands  of  Dr.  Edebohls,  who  reported  the 
results  of  examination  as  follows:  "Face,  anemic;  lips,  livid.  Large 
cavity  and  wide-spread  infiltration  in  anterior  portion  of  right  lung, 
middle  and  lower  lobes;  smaller  cavity  with  surrounding  infiltration 
in  left  lung,  middle  of  anterior  portion.  Rales  abundant  everywhere 
over  both  lungs.  Heart  hypertrophied,  with  apex-beat  disjilaced  to 
right;  no  murmurs.  Neither  kidney  palpable.  The  urine  ((iiitained 
30  per  cent,  of  albumin  by  bulk,  and  was  loaded  with  casts.  It  looked 
like  a  hopeless  case  from  any  point  of  view,  and  the  patient  was  so 
informed."  The  operation  was  performed  under  nitrous  oxid  and 
oxygen  in  October,  1903.  The  patient  is  still  alive,  and  enjoying  an 
active  busine.ss  career  in  Georgia.     Not  long  ago  I  had  opportunity  to 


144      SYMPTOMATOLOGY    AND    COURSE,  VARIETIES    AXD    TERMINATION 

examine  him  while  on  a  brief  visit  to  Colorado.  The  urine  is  diminished 
in  amount  and  contains  a  large  quantity  of  albumin  and  innumerable 
casts.  No  essential  change  was  noted  in  the  pulmonaiy  condition.  It 
is  difficult  to  realize  how  life  has  since  been  maintained  in  view  of  the 
physical  condition  of  the  lungs  five  years  ago,  and  the  complicating  renal 
involvement.  His  ability  to  be  about  on  his  feet  since  then  has  been 
an  ever-recurring  source  of  wonder.  I  have  learned  recently  of  a  severe 
uremic  attack  which  took  place  at  his  home,  but  from  which  he  is  now 
convalescing  satisfactorily. 

The  various  forms  of  chronic  kidney  disease  have  been  observed 
to  attend  more  frequently  the  long-standing  cases  of  consumption 
exhil)iting  cavity  formation  and  excessive  wasting.  Often  temporary 
albuminuria  is  found  coincident  with  large  pleural  effusions,  acute 
bronchopneumonia,  or  high  fever  from  any  cause. 

Acute  nephritis  is  not  especially  uncommon  among  consumptives. 
I  have  seen  it  follow  an  influenza  infection,  and  in  several  instances 
a  comparatively  mild  tonsillitis.  Nine  years  ago  a  gentleman  with 
extensive  double  pulmonary  tuberculosis  developed  a  most  severe 
nephritis  immediately  following  a  trifling  tonsillitis.  The  acute  symp- 
toms persisted  during  a  period  of  nearly  two  months,  and,  contrary 
to  all  reasonable  expectation,  the  patient  finally  made  a  complete 
recovery  in  spite  of  a  long-continued  uremic  condition. 

In  1901  a  patient  of  Dr.  Tyson  suddenly  developed  acute  uremic 
symptoms  almost  immechately  upon  arrival  in  Colorado.  She  remained 
profoundly  unconscious  for  tiventi /-three  daj's,  and  finally  recovered. 
Several  other  equally  striking  instances  can  be  enumerated  to  illustrate 
the  occasional  development  of  severe  acute  nephritis  following  appar- 
ently trifling  causes. 

With  reference  to  the  sexual  organs,  perhaps  the  most  frequent 
clinical  phenomenon  in  consumptives  is  the  disturbance  of  menstruation. 
As  the  disease  advances,  this  function  is  subject  to  considerable  derange- 
ment, which  becomes  the  source  of  much  anxiety  and  apprehension  to 
the  patient.  At  first  the  menstrual  discharge  is  noticetl  to  be  scanty 
and  of  pale  appearance.  It  subsequently  becomes  delayed,  irregular, 
more  scanty,  with  less  color,  and  finally  cfisappears  altogether.  As 
the  condition  improves  with  gain  in  strength  and  nutrition  these 
symptoms  reappear  in  an  inverse  order.  The  menstruation  often 
becomes  entirely  normal  even  after  its  suppression  during  protracted 
periods.     I  have  known  its  reappearance  after  the  lapse  of  two  years. 

It  is  a  common  belief  that  the  sexual  desire  in  consumptives  is 
increased  to  a  considerable  extent,  but  this  opinion  is  scarcely  borne 
out  by  the  facts.  As  far  as  the  pulmonary  involvement  itself  is 
concerned,  it  can  be  maintained  that  no  such  influence  obtains.  A 
partial  explanation,  however,  is  found  in  the  essentially  passive  exis- 
tence, absence  of  diverting  thoughts,  the  abundant  use  of  raw  eggs,  and 
the  daily  administration  of  strychnin.  In  some  cases  the  procreative 
power  persists  almost  to  the  point  of  death,  but,  as  a  general  rule,  the 
sexual  appetite  is  diminished  correspondingly  with  the  increasing 
exhaustion.  The  fact  that  a  few  exceptional  patients  retain  their 
vigor  in  spite  of  advanced  tuberculosis  constitutes  no  argument  capable 
of  general  application  with  reference  to  any  stimulating  influence  of  the 
disease. 


THE    CLINICAL    COURSE 


SECTION    11 
Course,  Varieties,  and  Termination 

chapter  xxvi 

THE  CLINICAL  COURSE 

The  course  of  pulmonary  tuberculosis  is  subject  to  a  degree  of  vari- 
ation unequaled  by  any  other  disease.  The  wide  diversity  of  clinical 
manifestations  among  different  invalids  is  responsible  for  essential  dif- 
ferences in  the  general  type,  duration,  and  termination.  The  general 
symptomatology,  however,  is  so  varied  in  character,  and  the  course 
so  susceptible  of  change  from  time  to  time  in  the  same  individual, 
as  to  preclude  an  arbitrary  classification  into  separate  groups.  It  has 
been  customary  to  recognize  two  chief  forms  of  pulmonary  tuberculosis — 
the  florid  galloping  phthisis,  or  "quick  consumption,"  and  the  chronic 
form  popularly  described  as  "old-fashioned  consumption."  A  dis- 
tinction based  upon  pathologic  changes  affords  further  subdivision 
into  three  stages,  i.  e.,  incipient  infiltration,  softening,  and  excavation. 
These  differences  in  the  stage  of  the  disease,  though  technically  capable 
of  pathologic  definition,  as  a  rule,  are  not  sufficiently  uniform  to  permit 
an  accurate  clinical  differentiation.  In  some  patients  the  type  may  be 
defined  distinctly  from  beginning  to  end,  and  the  various  stages  separated 
from  one  another  by  sharp  lines  of  clinical  demarcation.  Other  cases, 
far  from  pursuing  an  unvarying  course,  are  characterized  by  abrupt  and 
varied  changes.  In  addition  to  the  decided  complexity  of  svdjjective 
and  objective  manifestations  there  is  often  a  strikinjf  divergence  in  the 
nature  and  extent  of  pathologic  conditions.  Areas  of  arrest  may  exist 
in  immediate  juxtaposition  to  active  destructive  processes.  Within  a 
relatively  small  region  may  be  found,  severally,  an  incipient  infiltrative 
deposit,  an  area  of  secondary  bronchopneumonia,  one  of  caseous 
degeneration,  one  of  complete  fibrosis,  and  one  of  pulmonary  excavation, 
with  or  without  a  surrounding  zone  of  reactive  inflammation.  An 
explanation  of  the  subtle  variations  in  type,  and  the  sudden  trans- 
formation of  the  course,  is  found  in  the  further  dissemination  of  bacilli, 
differences  in  the  absorptive  capacity  for  toxins,  and  the  development 
of  wholly  unexpected  complications. 

Owing  to  the  intricate  character  of  the  finer  histologic  processes 
and  the  varying  changes  in  the  gross  pathology,  it  is  easy  to  comprehend 
the  wide  range  of  possibilities  in  the  duration  and  clinical  course.  The 
morbid  changes  produced  by  the  distribution  of  tubercle  bacilli  to 
previously  uninvaded  areas  vary  according  to  the  number  and  virulence 
of  the  bacilli  and  their  association  with  other  microorganisms.  Thus 
the  agents  of  secondary  infection  may  produce  sharp  exacerbations  of 
fever,  with  associated  disturbances,  and  occasionally  scattered  areas 
of  pneumonic  consolidation.  Often  the  effect  of  such  pathogenic 
microorganisms  as  the  micrococcus  lanceolatus,  the  streptococcus 
pyogenes,  the  staphylococcus  aureus,  or  the  bacillus  pyocyaneus  is 
10 


146      SYMPTOMATOLOGY    AND    COtiRSE,    VARIETIES    AND    TERMINATION 

sufficient  to  turn  apparent  success  into  disheartening  failure.  It  is 
well  known  that  conditions  existing  in  the  periphery  of  a  tuberculous 
focus  materially  influence  the  rapidity  and  extent  of  toxic  absorption. 
The  toxins  may  be  sufficiently  irritant  in  character  to  set  up  a  reactive 
inflammation,  which,  in  turn,  constitutes  a  barrier  against  further 
extension  of  the  infective  process.  Cornet  has  called  attention  to  a 
direct  relation,  conceived  to  exist  between  the  degree  of  absorption  and 
the  amount  of  poisonous  material  in  the  immecUate  environment  of 
the  tuberculous  focus.  He  believes  that  the  toxins  adjacent  to  the 
area  of  infection,  if  not  absorbed  too  rapidly,  may  aid,  through  their 
irritant  action,  in  compressing  the  lymph-channels  and  partially 
obliterating  the  smaller  blood-vessels.  This  presents  certain  obstacles 
to  the  extension  of  the  bacillary  infection  and  controls  to  some  extent 
the  further  absorption  of  the  poisons.  If  absorption  is  obstructed  in 
this  manner,  the  toxins  remain  in  clo.se  proximity  to  the  tubercle,  and 
at  this  point  exert  their  influence  upon  the  tissues.  It  would  appear 
that  a  lessened  absorptive  capacity  aids  in  the  formation  of  an  inflam- 
matory wall  around  the  focus  of  infection.  This  barrier  still  further 
lessens  the  opportunities  for  absorption  and  guards  against  further 
distribution  of  the  bacilli.  The  degree  of  absorption  and  the  pathologic 
change  in  the  periphery  are,  therefore,  more  or  less  interactive  in  their 
effect.  According  to  the  indestructibility  and  imperviousness  of  the 
barrier  will  absorption  of  toxins  and  egress  of  tubercle  bacilli  be  pre- 
vented. These  are  factors  of  the  utmost  importance  in  determining  the 
character  of  the  clinical  picture,  which  necessarily  is  modified  in  accord- 
ance with  essential  histologic  and  bacteriologic  changes.  Some  ca.ses  con- 
form .strictly  to  the  acute  type,  the  course  from  the  initial  symptoms  to 
the  end  being  completed  in  a  relatively  short  period.  Others  present 
throughout  the  disease  features  of  indefinite  chronicity,  to  the  exclusion 
of  acute  exacerbations  or  intercurring  complications.  There  still  remains 
a  large  class  who  exhibit  at  recurring  intervals  widely  differing  aspects  of 
the  affection.  In  this  group  of  cases  the  impression  received  by  the 
medical  attendant  regarding  the  probable  prognosis  may  be  either 
favorable  or  unfavorable,  according  to  the  particular  time  of  observa- 
tion. It  may  be  stated  that,  as  a  rule,  the  general  character  of  the 
clinical  manifestations  at  one  period  of  the  disease  affords  no  reliable 
criterion  as  to  the  nature  of  the  subsequent  course.  An  abrupt  develop- 
ment does  not  augur  necessarily  a  short  duration,  nor  does  a  subacute 
onset  presage  a  chronic  prolongation  of  the  disease.  As  a  result  of 
judicious  management,  reinforced  by  individual  powers  of  resistance, 
initial  acute  symptoms  may  become  subject  to  satisfactory  control, 
whOe  ca.ses  apparently  destined  to  a  prolonged  period  of  invalidism 
are  brought  to  a  sudden  termination  by  the  supervention  of  alarming 
manifestations.  The  possibility  of  pulmonary  hemorrhage,  like  the 
sword  of  Damocles,  must  hang  over  the  head  of  the  consumptive, 
irrespective  of  the  previous  history,  the  character  of  the  clinical  symp- 
toms, the  apparent  pathologic  condition,  or  the  duration  of  the  disease. 
Cases  characterized  by  an  acute  pneumonic  onset  and  those  of  general 
miliary  invasion  are  the  least  likely  to  undergo  a  change  in  the  subsequent 
progress.  Their  diu'ation  may  be  from  four  to  ten  or  twelve  weeks.  Many 
such  patients,  after  the  lapse  of  four  or  five  weeks,  have  sought  to  avail 
themselves  of  climatic  influence  and  have  survived  but  a  few  days  after 
arrival  in  Colorado.     The  inference  has  been  that  the  exhaustion  and 


SPECIAL    VARIETIES  147 

hardship  of  the  journey,  in  connection  with  the  sudden  change  of  alti- 
tude, have  hastened  a  fatal  termination.  Scattered  or  confluent  areas  of 
bronchopneumonia  ingrafted  upon  an  existing  pulmonary  tuberculosis 
frequently  render  the  disease  of  short  duration.  The  consolidation 
sometimes  extends  with  relentless  rapidity  to  a  massive  involvement, 
and  clearly  points  the  way  toward  the  end  of  the  journey.  Death  may 
ensue  in  a  week  or  ten  days,  owing  to  the  functional  incapacity  of  the 
lung  and  the  exhaustion  incident  to  the  toxemia.  In  some  instances 
the  patient  may  not  succumb  until  after  several  weeks,  during  which 
time  evidences  of  softening  and  excavation  are  recognized.  The 
shortening  of  the  course  through  the  influence  of  secondary  infection 
is  usually  less  conspicuous  than  from  pulmonary  hemorrhage  or  pneu- 
monic consolidation. 

It  is  extremely  difficult  to  generalize  concerning  the  duration  of 
the  cUsease.  This  has  been  variously  stated  bj^  observers  to  be  from 
two  to  seven  years,  yet  many  cases  are  known  to  survive  but  a  few 
months,  and  others  to  linger  for  fifteen  or  twenty  years.  The  latter 
often  present  from  time  to  time  undoubted  evidences  of  active  tubercu- 
lous involvement.  There  has  been  no  uniform  basis  for  the  computation 
of  statistics,  and  the  results  must  necessarily  vary  according  to  the 
character  of  the  cases  comj^rising  the  material  from  which  various 
analyses  are  collnb.irnl.Ml.  'Vlw  sdci.-il  <M)ii(liii(]ii  of  the  |i.'itifiit ,  the 
later  environment.  :iiiil  Ihc  ()ii|iiiriiiiiii  ic-  tnr  cnlui'iiim  :i  ^iriri  i'(\uinie 
constitute  imiiorlaiil  (Iclciiniiiiiiii:  ImcIois.  ( 'n^cs  i>)' inciinciil  i-lKiiiictcr 
admitted  to  sanatoriu,  |i(  riiiillcd  lo  iciiiain  for  considcralilc  jicikmIs, 
and  sulijfctf'd  to  f'(hic;ii i()ii;il  iiifliiriiccs  may  be  expected,  in  roni- 
parison  with  other  pulnidiiary  in\:iliils.  to  show  but  sli.iilit  lesseiiiiii:  of 
longevity.  The  experience  of  dlliei-  cll)se^^•ers.  many  of  ^\ll(lse  patients 
conform  to  an  advanced  tyjx',  is.  of  cdurse,  entirely  diffeveiit.  The 
deduction  is  inevitable  that  the  duration  of  jiulnionnr)-  jilithisis  in  must 
cases  is  dependent  upon  the  available  opi)ortunities  t<]  seiMii'e  ai-rest. 
Not  infrequently  the  character  of  the  clinical  course  is  iai\uely  a  nj.itter 
of  personal  equation.  A  large  majority  of  the  inteinu'rinfi  complications 
and  retrogressions  are  occasioned  either  by  the  ignorance  and  super- 
ficiality of  the  physician,  or  by  the  stubbornness  and  frivolity  of  the 
invalid.  The  willingness  and  ability  to  avoid  the  sins  of  omission  and 
commission  on  the  part  of  the  consumptive  are  most  potent  factors 
in  modifying  the   course  of  the  disease. 


CHAPTER  XXVII 
SPECIAL  VARIETIES 


In  addition  to  the  ordinary  forms  of  ulcerative  phthisis  which  have 
been  described,  other  varieties  ol'  i)ulniciiiary  infection  are  sometimes 
observed  presenting  such  peculi.n  itie,~  in  the  clinical  course  as  to  justify 
separate  classification.  There  are  three  special  forms  which  are  strik- 
ingly different  in  their  general  a.spects  from  the  ulcerative  type.  The 
first  is  fibroid  phthisis,  characterized  by  an  overgrowth  of  fibrous  tissue 


148      SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

originating  from  tuberculous  invasion  either  of  the  lungs  or  of  the 
pleura,  and  followed  by  extensive  pathologic  changes  involving  the 
pulmonary  tissues,  walls  of  the  bronchi,  and  the  circulatory  apparatus. 
The  second  is  pneumonokoniosis,  usually  owing  its  inception  to  an 
inhalation  bronchitis  which,  in  turn,  is  followed  by  emphysema,  fibrous 
tissue  change,  disturbance  of  circulation,  and  ultimate  tubercle  deposit. 
The  third  is  the  pulmonary  form  of  general  miliary  tuberculosis,  in 
which  the  bacilli  are  distributed  through  the  blood-stream,  the  resulting 
tubercles  literally  studding  extensive  portions  of  the  lung.  This  form 
of  pulmonary  invasion  will  be  considered  in  connection  with  General 
Miliary  Tuberculosis.  Brief  mention  should  be  made  of  fibroid  phthisis 
and  pneumonokoniosis  coexisting  with  pulmonary  tuberculosis. 

FIBROID   PHTHISIS 

The  term  fibroid  phthisis  should  be  applied  only  to  cases  of  extensive 
fibrous  tissue  proliferation  emanating  directly  from  a  primary  tubercle 
deposit  in  the  lung  or  pleura.  On  account  of  accompanying  pathologic 
changes  in  the  lungs,  bronchi,  and  vascular  sy.stem,  the  symptom- 
complex  rarely  conforms  to  the  clinical  picture  of  pulmonary  tubercu- 
losis. Tubercle  bacilli  may  be  unrecognized  in  the  expectoration,  or 
detected  only  in  small  numbers,  although  present  in  the  pulmonary 
tissues.  Inasmuch  as  a  preexisting  focus  of  infection  represents  the 
vmderlying  cause  of  fibroid  phthisis,  the  propriety  of  classifying  the 
condition  among  the  .several  forms  of  pulmonary  tuberculosis  is  at  once 
apparent.  In  order  to  avoid  confusion,  the  fibrous  tissue  change  of 
non-tuberculous  origin  should  be  described  as  pure  cirrhosis  of  the 
lung   or   chronic    interstitial    pneumonia. 

In  fibroid  phthisis  the  tubercle  deposit  finally  becomes  of  secondary 
importance  in  comparison  with  the  anatomic  changes  resulting  from 
the  primai'v  infection.  The  symptoms  referable  to  the  early  tuberculous 
invasion  either  disappear  entirely  or  become  subordinate  to  the  pre- 
ponderating fibrous  tissue  formation,  with  its  associated  functional 
disturbance.  The  entire  clinical  course  is  dominated  by  the  influence 
of  the  fibroid  overgrowth  permeating  the  pulmonary  tissues.  The 
duration  is  much  longer  than  that  of  ordinary  consumption,  the  invalids 
in  many  instances  surviving  for  astonishing  periods  despite  excessive 
emaciation  and  respiratory  incapacity.  Improvement,  even  under 
favorable  conditions,  is  correspondingly  slow  and  disappointing.  There 
is  usually  but  little  if  any  fever,  but  the  pulse  is  often  accelerated 
perceptibly  and  of  poor  quality.  The  cough  may  be  comparatively 
slight,  but,  as  a  rule,  is  somewhat  frequent,  dry,  and  paroxysmal.  The 
expectoration  in  most  instances  is  scanty  or  entirely  absent,  l)ut  if  at 
all  coijious,  is  more  likely  to  be  light  and  frothy  than  purulent  in 
character.  In  the  presence  of  bronchiectatic  cavities,  however,  the 
expectoration  is  often  distinctly  purulent  and  the  cough  markedly 
paro.xysmal.  In  such  cases  there  is  .sometimes  imparted  to  the  breath 
of  the  invalid  and  to  the  expectoration  a  particularly  offensive  odor. 
Digestive  di-^lurhmicos  nnd  iinpnirniont  of  appetite  are  frequent.  A 
beginning  shoitucss  of  l.icath  siradually  progresses  to  the  point  of  true 
dyspnea,  and  an  eaily  jjallor  may  finally  merge  into  varying  degrees  of 
cyanosis.  The  terminal  phalanges  become  clubbed  in  the  characteristic 
manner  previously  described. 


SPECIAL    VARIETIES  149 

It  is  scarcely  necessary  to  review  the  physical  signs  other  than  to 
allude  to  the  conspicuous  deformity  of  the  chest-wall  resulting  from 
the  pulmonary  and  pleural  retraction,  the  diminished  vocal  resonance 
and  fremitus  occasioned  by  the  pleural  thickening,  the  lessened  resonance 
upon  percussion,  and  the  reduced  intensity  of  the  respiratory  sounds 
upon  auscultation.  There  may  be  areas  of  bronchial  or  broncho- 
vesicular  respiration,  and  over  the  site  of  large  bronchiectases,  typically 
cavernous  breathing.  A  distinguishing  auscultatory  characteristic, 
aside  from  changes  of  quality,  pitch,  and  rhythm,  is  the  diminution 
of  the  breath-sounds  incident  to  lessened  respiratory  excursion  and 
excessive  pleural  thickening.  As  stated  elsewhere,  the  heart  is  almost 
always  pulled  more  or  less  toward  the  affected  side,  or  dislocated 
upward  by  reason  of  contraction  changes  involving  the  mediastinal 
pleura.  Occasionally  it  is  dilated  in  later  stages.  Reference  has  been 
made  to  the  visible  pulsation  from  the  second  to  the  fourth  interspaces 
in  case  of  left-sided  involvement.  The  exti'eme  chronicity  of  the  course, 
the  occasional  absence  of  the  bacilli,  and  the  infrequency  of  fever, 
together  with  the  energy  and  vitality  displayed  in  spite  of  excessive 
emaciation,  serve  to  characterize  definitely  this  foi-m  of  pulmonary 
tuberculosis. 

PNEUMONOKONIOSIS 

In  pneumonokoniosis  the  pathologic  changes  may  closely  simulate 
those  of  fibroid  phthisis.  An  essential  difference  relates  to  the  etiologic 
relation  of  the  tubercle  bacillus  to  the  accompanying  anatomic  condition. 
The  tubercle  deposit  is  in  no  sense  a  causal  factor  in  the  production  of 
pneumonokoniosis,  but  takes  place  merely  as  a  terminal  infection. 
The  primary  cause  consists  chiefly  of  an  inhalation  bronchitis  through 
continuous  exposure  to  the  palpable  dust  incident  to  certain  occupations. 
It  differs  clinically  from  fibroid  phthisis  in  that  the  course  of  the  disease 
is  of  much  shorter  duration,  and  the  fibrous  tissue  jnoliferation  usually 
not  so  extreme,  with  less  resulting  deformity  of  tlic  cliost.  The  ingraft- 
ing of  the  tuberculous  infection  upon  a  suitaMc  soil,  represented  by  a 
weakened  general  resistance  and  increased  vulnerability  of  ti-ssues, 
affords  opportunity  for  comparatively  rapid  progress.  In  miners, 
grinders,  and  stone-cutters,  once  the  tuberculous  character  of  the 
infection  is  clearly  established,  I  have  been  unable  to  discover  that  the 
symptoms  differ  very  essentially  from  those  of  ordinary  pulmonary 
tuberculosis. 

I  have  been  privileged  to  observe  a  moderate  number  of  cases  of 
pneumonokoniosis  with  accompanying  tuberculous  infection  among  the 
gold-miners  of  Colorado.  In  the  very  midst  of  all  stages  and  conditions 
of  imported  pulmonary  tuberculosis  in  Denver,  there  are  foimd 
numerous  ca.ses  of  miner's  phthisis,  difficult  of  differentiation  from 
consumption,  yet  scarcely  identical  with  it.  There  are  certain  etiologic 
factors  pertaining  to  the  condition  which  lend  a  more  or  less  unique 
character  to  this  class  of  cases.  As  stated  in  connection  with  Differ- 
ential Diagnosis,  these  patients  may  exhibit  all  the  symptoms  and  signs 
of  pulmonary  tuberculosis,  and  in  the  later  stages  show  the  presence  of 
tubercle  bacilli,  although  the  latter  do  not  represent  a  factor  of  causative 
significance.  This  class  of  cases  is  regarded  by  the  laity,  and,  unfor- 
tunately, to  some  extent  by  the  profession,  as  a  form  of  consumption, 
and  many  such  patients  are  classified  as  tuberculous  in  official  mortality 


150       SYMPTOMATOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 

records.  Instances  of  pneumonokoniosis  are  frequently  cited  to  illus- 
trate the  alleged  development  of  indigenous  tuberculosis  in  spite  of 
favorable  climatic  conditions.  The  actual  morbid  processes  consist 
of  a  more  or  less  severe  chronic  bronchitis,  emphysema,  bronchiectasis, 
varying  degrees  of  pneumonokoniosis,  with  often  genuine  cavity  for- 
mation resulting  from  anemic  necrosis,  and  secondary'  circulatory 
disturbances.  The  tubercle  deposit,  if  present,  is  often  quite  insignifi- 
cant in  comparison  with  accompanj'ing  pathologic  changes.  These 
cases  are  found  to  develop  almost  exclusively  in  .sections  of  the  State 
devoted  to  the  mining  industry,  i.  e.,  in  sparsely  settled  regions  on 
mountain  siiles  where  tuberculosis  seldom  exists.  Prechsposing  causes 
are  found  in  the  prolonged  hours  underground  and  the  constant  breathing 
of  an  atmosphere,  not  only  deficient  in  oxj'gen.  but  vitiated  by  impuri- 
ties. The  air,  not  being  in  motion,  becomes  more  or  less  devitalized 
and  is  breathed  over  and  over  again.  In  addition  to  the  partial 
asphyxiation  and  the  frequent  extreme  dampness,  exciting  causes  relate 
to  exhalations  from  the  cantUes  confined  within  a  relatively  small 
air-space,  and  the  smoke  resulting  from  the  blasting  powder,  which  is 
difficult  of  complete  removal  despite  modern  efforts  toward  ventilation. 
The  necessarily  constrained  position  during  the  greater  portion  of  the 
day,  the  frequent  wetting  of  the  feet,  the  alcoholic  habits,  immoderate 
exercise  at  high  altitudes,  and  the  unhygienic  surrountUngs  when  not 
at  work,  constitute  important  supplemental  features.  The  conditions 
are  quite  dissimilar  to  those  obtaining  in  the  production  of  coal-miner's 
consumption,  stone-cutter's  disease,  grinder's  or  potter's  phthisis,  and 
the  like,  in  that  the  sole  essential  factor  is  not  the  irritation  produced 
by  the  inhalation  of  fine  particles  of  dust.  Chronic  catarrhal  processes 
take  place  in  the  bronchial  mucous  membranes,  followed  by  emphysema 
which  results  fnnii  nutritional  changes  in  the  pulmonary  tissues,  and 
from  an  increased  intra-alveolar  pressure  during  violent  attacks  of  cough. 
Moderate  fibrous  tissue  proliferation  is  superinduced  in  .some  cases, 
but  by  no  means  to  the  extent  observed  among  followers  of  other 
occupations  responsible  for  the  production  of  pneumonokoniosis. 
AVhile  the  distinguishing  feature  is  the  chronic  bronchitis  and  emphy- 
sema, there  frequently  supervenes  bronchiectasis,  both  of  the  cylindric 
and  saccular  varieties.  Its  development  is  due  in  part  to  the  frequent 
paroxysmal  cough,  the  weakening  of  the  l^ronchial  wall  from  emphysema, 
and  the  more  or  less  continuous  pressure  exerted  by  stagnating  secre- 
tions. The  bronchiectatic  cavities  correspond  largely  to  the  fibrous 
tissue  proliferation  and  the  contraction  changes  external  to  the  bronchial 
wall.  Through  the  process  of  ulceration  of  the  mucous  membranes 
these  bronchiectases  may  be  transformed  into  genuine  pulmonary 
cavities.  These  may  develop  also  by  reason  of  necrotic  softening  of 
the  tissues,  more  particularly  when  the  pneumonokoniosis  is  pro- 
nounced. In  this  event  they  are  more  likely  to  increase  in  size  and  have 
greater  bearing  on  the  subsequent  course,  especially  if  commimicating 
with  a  bronchial  tube.  Secondare  to  the  pulmonary  changes  there 
ensue  marked  circulatory  disturbances,  manifested  by  venous  engorge- 
ment and  enlargement  of  the  right  heart. 

Symptoms  referable  to  this  group  of  chronic  pathologic  conditions 
are  of  gradual  development  and  relate  chieflj*  to  dyspnea,  cough,  and 
expectoration,  followed  by  loss  of  weight  and  strength,  with  gradually 
increasing  cyanosis.     The  cough  is  frequent  and  unattended  at  first 


SPECIAL    VARIETIES  151 

■with  much  expectoration.  Later  it  becomes  more  distressing  and 
paroxysmal  in  character,  particularly  after  the  formation  of  bron- 
chiectases or  pulmonary  cavities.  There  exists  no  definite  relation 
between  the  degree  of  bronchial  irritation  and  the  extent  of  fibroid 
change  in  the  lung.  The  sputum  is  frequently  quite  frothy,  light, 
and  devoid  of  pigmentation,  becoming  more  purulent  with  the  increasing 
periodicity  of  cough.  Under  these  conditions  the  characteristic  sepa- 
ration into  distinct  layers  may  be  noted.  Little  of  practical  value 
attaches  to  its  bacteriologic  examination,  save  that  the  occasional 
presence  of  tubercle  bacilli  denotes  a  final  incidental  complication. 

The  dyspnea,  which  at  first  is  noticeable  only  upon  slight  exertion, 
becomes  progressively  worse,  until  the  patient  is  induced  to  seek  relief 
at  lower  elevations. 

The  cyanosis  is  usually,  out  of  proportion  to  the  physical  evidences 
of  cardiac  and  respiratory  embarrassment.  Impaired  appetite  and 
digestive  disturbances  result  in  diminished  nutrition,  increasing  weak- 
ness, and  night-sweats.  There  is  rarely  any  elevation  of  temperature 
save  during  temporary  acute  exacerbations. 

Hemorrhages  are  not  infrequent,  and  may  vary  from  slight  bloody 
discolorations  of  sputum  to  a  sudden  fatal  loss  of  blood. 

The  physical  signs  upon  inspection  may  consist  of  the  characteristic 
■changes  in  the  configuration  of  the  thorax  commonly  ascribed  to  emphy- 
sema, with  frequent  unilateral  or  bilateral  retraction  of  the  apices  and 
occasional  capillary  dilatation  upon  the  chest  front.  There  are  often 
percussion-signs  of  partial  consolidation  at  the  apices,  but  in  many  cases 
the  resonance  is  intensified  and  somewhat  tympanitic  throughout  the 
entire  pulmonary  area.  Fine  and  medium-sized  moist  rales  may  be 
heard  in  all  portions  of  the  lung,  though  more  frequently  at  the  bases 
and  almost  always  on  each  sicle.  The  breath-sounds  are  invariably 
somewhat  diminished  in  intensity,  corresponding  to  the  degree  of 
emphysema.  The  dulness  is  occasionally  unilateral,  in  which  event 
there  often  are  localized  changes  in  pitch,  quality,  and  rhythm,  and 
■bubbling  rales.  Signs  suggestive  of  pulmonary  cavities  may  be  recog- 
nized in  almost  any  portion  of  the  lung,  as  in  tuberculosis.  There  is 
no  invariable  predilection  as  to  the  site  of  the  cavity  formation. 

In  comparison  with  simple  chronic  bronchitis  and  emphysema,  or 
with  ordinary  cases  of  interstitial  pneimionia,  the  course  of  the  disease 
is  short,  rarely  lasting  over  four  or  five  years.  This  may  be  accounted 
for  to  some  extent  by  the  influence  of  altitude,  the  usual  unwillingness 
and  inability  of  patients  to  avail  themselves  of  change  of  residence, 
and  their  greatly  diminished  resistance  from  habits  of  dissipation. 
While  considerable  relief  is  usually  experienced  on  going  to  lower 
elevations,  the  unfortunate  issue  is  delayed  but  temporarily,  the 
prognosis  almost  always  being  unfavorable. 


152      SYMPTOMAIOLOGY    AND    COURSE,    VARIETIES    AND    TERMINATION 


CHAPTER  XXVIII 

TERMINATION 

Strictly  speaking,  the  ultimate  termination  is  recovery  or  death, 
but  a  large  number  of  cases  cannot  properly  be  included  in  either 
class.  While  not  actually  cured,  they  are  none  the  less  enabled, 
for  indefinite  periods,  to  pursue  a  life  of  useful  endeavor  within  the 
bounds  of  considerable  physical  activity.  In  its  technical  sense  com- 
plete recovery  is  relatively  infrequent  save  in  the  most  incipient  cases, 
as  the  infected  area  is  scarcely  capable  of  restoration  to  its  previous 
condition.  The  very  conception  of  an  enduring  arrest  carries  with  it 
the  necessity  of  fibrous  tissue  proliferation  and  encapsulation,  but  it 
is  unreasonable  to  deny,  because  of  resulting  anatomic  change,  the 
attainment  of  complete  recovery.  A  permanent  arrest  of  the  tubercu- 
lous lesions  is  no  less  a  cure  despite  a  remaining  indurative  process  than 
recovery  from  variola  with  resulting  facial  blemishes.  It  is  entirely 
warrantable  to  regard  patients  as  cured  who,  during  a  period  of  two  or 
three  years,  present  no  physical  signs  of  even  a  dormant  infection, 
exhibit  no  subjective  symptoms,  and  display  an  invariable  ab-sence  of 
tubercle  bacilli.  It  is  not  contended  that  bacilli  may  not  exist  in  the 
pulmonary  tissues  of  such  patients,  but  the  non-development  of  any 
signs  or  symptoms  suggestive  of  their  presence  during  a  prolonged 
period  may  be  construed  as  sufficient  evidence  of  their  practical  sur- 
render. Many  patients  fail  to  succeed  in  the  acquirement  of  complete 
arrest,  and  yet  possess  undiminished  vigor  and  activity.  It  is  common 
in  health  resorts  to  observe  a  large  class  of  inchviduals  who  have  achieved 
apparent  arrest  of  the  active  process.  Many  of  these  with  entire  dis- 
appearance of  subjective  symptoms  e.xhibit  renewed  energj^  and  industry, 
yet  at  intervals  display  a  few  apical  signs,  with  attenuated  bacilli  in 
the  expectoration.  I  have  under  my  care  several  patients  who  have 
remained  in  Colorado  for  thirty  years  or  more,  and  who  present  every 
outward  and  physical  manifestation  of  perfect  health,  although  occa- 
sionally submitting  bacteriologic  evidences  of  a  remaining  quiescent 
deposit. 

MODES  OF  DEATH 

For  some  unexplainable  reason  death  from  consumption  has  ever 
been  thought  to  be  particularly  horrible  and  revolting.  It  is  possible 
that  the  idea  of  a  lingering  illness,  a  so-called  "dying  by  inches,"  has 
suggested  to  the  popular  mind  an  exaggerated  notion  of  the  physical 
distress  during  the  final  agony.  There  is  no  reason  to  believe  that  the 
dissolution  of  the  consumptive  is  attended  by  a  greater  physical 
struggle  or  mental  anguish  than  is  experienced  bj-  other  victims  of  the 
grim  destroyer.  In  many  cases  the  prolonged  duration  of  the  illness, 
rather  than  making  death  harder  to  bear,  is  instrumental  to  a  degree  in 
preparing  the  sufferer  to  bear  the  inevitable  with  fortitude  and  resigna- 
tion. With  many  the  end  is  a  welcome  relief  from  the  burdens  and 
hardships  incident  to  their  illness.  Patients  of  this  class,  far  from 
approaching  their  demise  with  fear  and  trepidation,  long  for  eternal 
rest  with  a  courage  and  calmness  incapable  of  simulation. 


TERMINATION  153 

Many  times  have  I  been  impressed  most  profoundly  by  the  remark- 
able resignation  of  the  consumptive,  who,  with  unclouded  intellect,  has 
responded  to  the  last  summons.  It  has  appeared  that  the  very  nature 
of  the  illness  has  tendetl  to  dispossess  the  end  of  its  ordinary  terrors, 
and  to  render  the  anticipation  of  the  supreme  moment  but  a  deferred 
solace  for  botlily  ills.  Many,  it  is  true,  preserve  a  demeanor  of  indiffer- 
ence in  the  face  of  impending  death,  while  others,  with  halting  tread  and 
protestation,  are  dragged  to  their  doom.  Fortunately,  mental  hebetude 
sometimes  comes  to  the  rescue,  foUowetl  by  mild  (lelirium  and  coma, 
and  the  patient  sinks  gently  to  the  final  sleep.  The  tlemise  of  the  con- 
sumptive, as  a  general  rule,  is  singularly  quiet  and  peaceful,  devoid  in 
large  measure  of  the  struggle  and  anguish  characterizing  a  fatal  termi- 
nation of  other  disea.ses.  It  has  been  my  observation  that  the  only 
conspicuous  deviation  from  tliis  manner  of  departure  occurs  among 
pulmonary  invalids  overtaken  by  death  as  a  result  of  intercurrent  com- 
plications. This  is  particularly  true  in  pulmonary  hemorrhage,  bron- 
chopneumonia, edema  of  the  lungs,  i)neumothorax,  cardiac  dilatation, 
and  occasionally  tuberculous  meningitis. 

The  end  may  be  sudden  and  violent,  as  during  severe  pulmonary 
hemorrhage.  At  such  a  time  the  patient  is  drowned  in  his  own  bloocl, 
and  may  expire  almost  immediately  from  asphyxiation,  the  suffering 
being  but  momentary.  Dissolution  may  take  place  suddenly  from  other 
causes,  as  cardiac  weakness  or  bronchopneumonia.  I  have  witnessed 
two  instances  of  sudden  death  following  light  percussion  of  the  precor- 
dial region  in  cases  of  cardiac  dilatation. 

In  bronchopneumonia  of  septic  origin  following  pulmonary  hemor- 
rhages the  patient  is  at  first  restless,  anxious,  and  excitable.  After 
a  few  days  this  changes  to  apathy,  stupor,  mild  delirium,  and  some- 
times coma.  In  some  instances  of  death  from  aspiiation  pneumonia 
the  sensorium  remains  unimpaired  to  the  last,  and  the  air-hunger 
becomes  extreme.  This  may  happen  also  in  pneumothorax,  and  almost 
invariably  in  pulmonary  edema.  In  such  cases  the  suffering  is  more 
intense  than  can  be  imagined  or  described.  Dreadful  paroxysms  of 
cough  sometimes  suffice  to  expel  foamy  and  bloody  expectoration, 
causing  the  disappearance,  for  the  time  being,  of  the  ominous  tracheal 
rattle. 

In  acute  pneumothorax  and  in  bronchopneumonia  without  edema 
there  may  be  no  expectoration  whatever.  At  times  there  is  insufficient 
strength  to  efTect  the  expulsion  of  the  expectoration,  which,  if  present 
at  all,  sticks  to  the  lips  and  dorsal  aspect  of  the  tongue  or  adheres 
tenaciously  to  its  base  and  to  the  posterior  wall  of  the  pharynx.  The 
mouth  and  lips  are  exceedingly  dry,  and  the  masses  of  sputum  are 
extracted  only  by  means  of  a  cloth  or  swab.  The  struggle,  which  is 
horrible  to  witness  or  contemplate,  continues  without  abatement  until 
merciful  death  claims  its  own.  As  a  general  rule,  however,  it  seems  to 
be  a  beneficent  provision  of  nature  that  the  vast  majority  of  consump- 
tives, after  months  and  years  of  lingering  illness,  are  permitted  to  suc- 
cumb to  the  dread  disease  without  sthenic  manifestations. 


PART   111 
PHYSICAL  SIGNS 


INTRODUCTION 

Pulmonary  tuberculosis  produces  a  greater  diversity  of  morbid 
conditions  within  the  lungs,  and  hence  exhibits  a  greater  variety  of 
physical  signs,  than  any  other  respiratory  affection.  There  is  scarcely 
an  objective  manifestation  observed  in  the  course  of  the  various 
pulmonary  diseases  which  may  not  be  exhibited  by  the  consumptive 
as  a  direct  result  of  the  pathologic  change  incident  to  the  tuberculous 
process  or  to  associated  complications.  Thus  an  accurate  recognition 
of  the  physical  signs  accompanying  the  varying  degrees  of  tuberculous 
infection  can  be  secured  only  from  a  thorough  understanding  of  the 
principles  of  physical  diagnosis  as  applied  to  all  intrathoracic  distur- 
bances. The  confusion  resulting  from  an  incorrect  terminology,  the 
frequent  errors  of  technic  in  conducting  physical  examinations,  and 
the  faulty  interpretation  of  various  combinations  of  physical  signs  are 
often  responsible  for  the  non-recognition  of  gross  pathologic  lesions, 
and  suggest  the  expediency  of  introducing  a  preliminary  section  devoted 
to  physical  diagnosis  in  general.  In  view  of  the  difficulties  often 
encountered  regarding  many  important  features  relating  to  the  physical 
examination  of  the  chest,  it  seems  desirable  to  outline  a  course  of  pro- 
cedure emphasizing  the  essential  principles  of  diagnosis  pertaining  to 
pulmonary  conditions. 

In  no  other  department  of  medicine  is  there  demanded  such  a  degree 
of  skill  as  in  the  recognition  of  obscure  pulmonary  affections.  In  all 
respiratory  diseases  a  precise  conception  of  the  condition  can  be  obtained 
only  through  an  exhaustive  and  systematic  examination  of  the  patient. 

While  during  student  life  dispensary  facilities  may  be  depended 
upon  to  furnish  the  means  of  acquiring  a  more  or  less  practical  famil- 
iarity with  the  making  of  physical  examinations,  these  clinical  oppor- 
tunities will  scarcely  suffice  for  a  thorough  understanding  of  the  subject 
unless  preceded  and  accompanied  by  competent  instruction  concerning 
the  principles  and  facts  of  physical  cUagnosis.  To  obtain  practical 
proficiency  it  is  highly  important  that  a  preparatory  course  of  didactic 
or  text-book  instruction  should  be  provided  not  only  as  to  the  physical 
signs  themselves,  but  as  well  to  the  rationale  of  their  production.  Thus, 
in  addition  to  the  recognition  of  abstract  physical  signs,  the  beginner 
should  be  made  to  appreciate  the  relation  of  the  various  phenomena 
thus  observed  to  the  morbid  conditions  which  they  represent.  Although 
no  single  physical  sign  may  be  said  to  characterize  definitely  any  path- 
ologic state  of  the  tissues  within  the  thora.x,  yet  the  grouping]  of  several 
associated  signs  in  connection  with  essential  facts  pertaining  to  the 
history  and  symptoms,  permits  the  differentiation  of  the  various  con- 
ditions. It  is  not  permissible  within  the  limited  scope  of  this  section  to 
do  other  than  review  important  features  of  diagnosis. 
154 


INSPECTION  155 

Various  methods  are  employed  for  the  recognition  of  diseased  con- 
ditions by  means  of  external  evidences.  Physical  signs  refer  to  objective 
manifestations  elicited  by  the  physician,  as  contrasted  with  subjective 
symptoms  described  by  the  patient.  The  physician  utilizes  the  following 
methods  of  conducting  a  physical  examination  of  the  chest,  i.  e.,  inspec- 
tion, palpation,  percussion,  auscultation,  mensuration,  and  succussion. 


SECTION    I 
General  Physical  Signs 

chapter  xxix 

INSPECTION 

While  much  may  be  learned  by  inspection,  the  relative  importance 
of  this  method  of  conducting  physical  examinations  is  often  exaggerated, 
the  tendency  of  several  writers  having  been  to  overestimate  its  value. 
It  is  by  no  means  impossible  for  one  who  is  totally  blind  to  be  fully  as 
skilful  in  physical  exploration  of  the  chest  as  expert  examiners  who  are 
not  deprived  of  the  sense  of  sight.  In  fact,  inspection  may  often  give 
rise  to  erroneous  impressions  regarding  physical  conditions  which  can 
be  removed  only  by  careful  recourse  to  other  methods  of  examination. 
It  is  not  infrequent  for  individuals  to  present  every  visual  manifestation 
of  perfect  health  and  yet  disclose  important  changes  upon  percussion 
or  auscultation.  It  is  equally  true  that  others  may  exhibit  many 
outward  appearances  of  pulmonary  disease,  even  displaying  well- 
developed  types  of  the  so-called  paralytic  thorax  or  phthisical  chest, 
and  yet  upon  examination  reveal  no  pathologic  pulmonary  condition. 
It  is  apparent,  therefore,  that  inspection  should  be  i-egarded  strictly 
as  an  aid  to  the  examiner  supplementary  to  other  means  of  physical 
exploration.  It  furnishes  to  some  extent  preliminary  impressions  or 
provisional  information,  which,  in  all  cases,  should  be  confirmed  by  the 
employment  of  other  methods. 

RULES  FOR  THE  PRACTICE  OF  INSPECTION 

Inspection  may  be  employed  with  the  patient  standing,  sitting,  or 
reclining.  If  standing,  the  body  should  be  held  erect  in  an  attitude  of 
repose,  with  the  weight  borne  equally  upon  each  foot.  The  head  should 
rest  squarely  upon  the  shoulders,  which  should  be  drawn  slightly  back- 
ward and  held  symmetrically.  Care  should  be  taken  to  avoid  the  slouch- 
ing posture  frequently  assumed  by  pulmonary  invalids.  Equal  pre- 
caution should  be  exercised  to  prevent  the  tendency  to  throw  the 
shoulders  far  backward  and  inflate  the  chest,  either  with  or  without 
retracting  the  abdomen.  When  the  patient  is  told  to  stand  erect, 
sometimes  an  appearance  is  presented  suggesting  a  military   inspection 


156  PHYSICAL    SIGNS 

during  dress  parade.  He  should  be  taught  simply  to  assume  a  natural 
posture.  The  examiner  should  remain  between  the  patient  and  the 
light.  It  is  well  for  the  physician  at  first  to  stand  some  little  distance 
from  the  patient,  in  order  to  appreciate  better  the  shape,  size,  and  form 
of  the  chest,  to  note  irregularities  of  contour  or  other  asymmetric  con- 
ditions, and  to  study  carefidly  changes  in  the  frequency  and  character 
of  the  respiratory  movements. 

If  the  patient  is  e.xamined  while  sitting,  a  moderately  high  stool 
or  straight -backed  chair  should  be  used.  In  most  eases  a  stool  is  pre- 
ferable, the  back  of  the  chair  possessing  no  particular  advantage  and 
often  being  in  the  way.  The  habit  of  slouching  is  noticed  more  often 
with  the  patient  sitting  than  standing,  and  should  be  avoiiled  in  all 
cases.  It  is  good  practice,  however,  when  examining  the  back,  to 
have  the  patient  incline  slightly  forward  with  the  arms  folded,  each 
hand  resting  upon  the  opposite  shoulder,  and  the  elbows  kept  as  closely 
together  as  possible.  This  expands  the  broad  wings  of  the  scapulse, 
which  in  emaciated  people  are  very  prominent,  and  permits  a  more  ready 
examination  of  the  back  than  can  be  obtained  in  any  other  position. 

The  examination  of  a  male  should  be  conducted  with  the  patient 
stripped  to  the  skin  as  far  as  the  waist.  There  can  be  no  excuse  for 
neglect  to  insist  upon  this  procedure.  With  females  it  is  not  always 
expedient,  on  the  score  of  delicacy,  to  demand  the  entire  removal  of  the 
clothing.  A  light  shawl  or  cape  may  be  drawn  over  the  back  when  the 
front  is  being  inspected,  and  vice  versa.  If  the  undershirt  is  loose,  it 
may  be  separated  in  front  and  dropped  over  the  shoulders,  or  it  may 
be  raised  from  below,  while  examining  respectively  the  upper  and  lower 
regions  of  the  chest. 

If  the  examination  is  made  with  the  patient  reclining,  care  should 
be  taken  that  the  body  rests  equally  upon  the  hips  and  shoulders,  with 
the  head  but  moderately  elevated.  Inspection  of  the  chest  with  the 
patient  reclining  can  be  but  superficial  at  be.st,  and  when  necessarily 
confined  in  bed,  this  method  of  examination  is  often  comparatively 
unimportant. 

CONDITIONS    INDEPENDENT    OF    THE    THORAX    NOTED    ON 
INSPECTION 

It  is  usually  taught  that  inspection  should  be  employed  particularly 
to  note  the  configuration  and  movements  of  the  thora.r  proper. 

As  a  matter  of  fact,  valualjle  suggestions  as  to  the  general  condition 
may  be  olitained  through  the  sense  of  sight  Ions;  before  the  patient  has 
been  stripped  to  the  waist  for  the  examination  of  the  chest.  For 
example,  the  examiner  unconsciously  notes  the  degree  of  emaciation, 
the  general  carriage  or  demeanor,  and  the  extent  of  physical  weakness. 
Great  practical  importance  in  a  general  estimate  of  the  patient's  con- 
dition attaches  to  the  facial  appearance.  The  first  impression  conveyed 
to  the  mind  of  the  examiner  usually  relates  to  the  visil)le  changes  of  the 
face,  whether  healthy  or  unhealthy,  full  or  emaciated,  pale  or  flushed, 
sallow,  cachectic  or  cyanotic,  dull  or  alert,  pinched,  drawn,  or  excitable, 
the  various  shades  of  expression  being  noted  at  a  glance.  The  color 
of  the  face  is  always  of  clinical  interest,  .\nemia  is  often  present, 
particularly  in  cases  of  pulmonary  tuberculosis.  This  is  more  surely 
detected  by  depressing  the  lower  eyelid  and  observing  the  color  of  the 


INSPECTION  157 

mucous  membrane.  Congestion  of  the  face  is  frequently  noted  in 
chronic  bronchitis  with  emphysema,  bronchiectasis,  in  the  early  stages 
of  pneumonia,  and  in  several  forms  of  circulatory  disturbance. 

Cyanosis  is  possessed  of  great  significance.  It  consists  of  a  purplish- 
blue  flush,  at  first  appearing  upon  the  lips,  tip  of  the  no.se,  and  the  ears, 
but  later  suffusing  the  entire  face.  This  may  be  present  as  a  result 
of  valvular  heart  lesions,  with  or  without  dilatation,  myocarditis, 
pericardial  effusion,  emphysema,  asthma,  pulmonary  edema,  chronic 
bronchitis,  and  occasionally  in  pulmonary  tuberculosis  with  circulatory 
embarrassment. 

Edema  of  the  face  is  often  observed  when  no  suggestion  of  patho- 
logic change  can  be  obtained  upon  inspection  of  the  thorax  alone. 
Facial  edema  may  fail  of  recognition  in  some  instances,  as  the  clinician 
may  not  be  sufficiently  familiar  with  the  contour  and  appearance  to 
make  comparative  observations.  The  careful  examiner,  however,  will 
usually  note  the  slight  puffiness  of  the  eyelids,  even  upon  casual  obser- 
vation. Critical  inspection  of  the  face  and  neck  should  precede  the 
examination  of  the  chest  in  all  instances. 

Great  importance  attaches  to  the  frequency  and  character  of  the 
respiration,  which  may  be  observed  quite  accurately  before  the  patient 
is  prepared  for  a  conventional  inspection.  While  a  detailed  observation 
of  the  nature  of  respiratory  movements  is  not  possible  without  the 
removal  of  the  clothing,  it  is  easy,  nevertheless,  to  recognize  the  presence 
or  absence  of  dyspnea.  This  may  exist  either  as  labored  respiration  or 
merely  as  quickened  breathing.  The  former  is  detected  long  before  the 
clothing  is  removed,  and  is  accompanied  by  more  or  less  cyanosis,  with 
an  increased  play  of  the  auxiliary  muscles  of  respiration.  Simple 
accelerated  breathing  without  cyanosis  and  unaccompanied  by  the  use 
of  the  accessory  muscles  of  respiration  may  result  from  such  causes  as 
emotional  excitement,  fever,  and  exercise. 

Labored  breathing  or  true  dyspnea  may  be  dependent  upon  a  dimin- 
ished respiratory  capacity  of  the  lungs  in  the  course  of  pulmonary 
tuberculosis,  pneumonia,  pleurisy  with  effusion,  pneumothorax,  and 
emphysema;  from  cardiac  disturbance  or  from  a  .severe  anemia. 

Change  from  the  normal  lireathing  may  also  be  recognized  in  the 
rhythm  and  sound  of  the  respirations.  In  some  cases  the  disturbed 
rhythm  relates  solely  to  the  changed  relations  between  inspiration 
and  expiration,  each  respiratory  act,  however,  being  identical  in 
character  with  all  others.  At  other  times  the  altered  rhythm  relates 
not  so  much  to  a  disturbance  of  the  relation  between  inspiration  and 
expiration,  as  to  radically  differing  characteristics  of  succeeding  respira- 
tory acts.  An  example  of  the  first  class  is  the  so-called  asthmatic 
breathing,  in  which  the  inspiration  is  shorter  and  quicker  than  normal, 
while  the  expiration  is  prolonged  and  difficult.  The  most  striking 
illustration  is  witnessed  during  an  acute  paroxysm  of  bronchial  asthma, 
but  this  form  of  breathing  is  displayed  to  a  less  degree  in  well- 
marked  emphysema.  In  the  latter  event  the  inspirations  are  not  so 
short  and  jerky  and  the  expirations  are  less  prolonged  and  labored. 
In  well-marked  asthmatic  breathing  the  sound  is  an  element  of  some 
interest  in  that  the  respiration  is  decidedly  wheezy  in  character. 

The  disturbance  of  rhythm  which  takes  place  in  succeeding  respira- 
tions is  found  in  the  so-called  Cheyne-Stokes  type  of  breathing. 
This  form  of  respiration  may  be  desi-ribed  as  an  alternating  cycle  of 


158  PHYSICAL    SIGNS 

progressively  increasing,  followed  by  gradually  decreasing,  dyspnea, 
and  periods  of  complete  apnea.  In  this  type  of  breathing  each 
act  of  respiration  is  different  from  the  preceding  or  the  following. 
The  patient  in  the  beginning  of  his  rhythmic  dyspnea  breathes  but 
little  differently  from  normal.  Each  following  respiration,  however, 
becomes  rapidly  increased  in  volume  and  louder  in  intensity  until  the 
height  of  the  dyspneic  attack  is  reached,  when  the  respirations  diminish 
inversely  in  rapidity,  volume,  and  intensity,  to  be  succeeded  by  a  com- 
plete pause  or  absence  of  respiration,  called  the  apneic  period.  The 
entire  cycle  may  last  anywhere  from  half  a  minute  to  a  full  minute.  In 
this  type  of  breathing,  as  in  the  asthmatic,  the  disturbed  rhythm  is 
associated  with  an  appreciable  difference  in  the  intensity  and  quality 
of  the  respiratory  sounds. 

Another  class  of  eases  exhibits  a  distinctly  restrained  respiration, 
particularly  during  inspiration,  which  is  short  and  conies  to  an  abrupt 
termination  appai'ently  before  the  act  of  inspiration  is  fully  completed. 
It  is  usually  associated  with  a  prolonged  slow  and  cautious  expiration. 
This  peculiarity  of  respiration  is  found  principally  in  cases  of  dry  pleurisy, 
in  the  very  early  stages  of  pneumonia,  and  as  a  result  of  intercostal 
neuralgia,  periostitis,  or  trauma.  The  restrained  or  catchy  respiration 
should  be  distinguished  from  a  type  of  irregular  breathing  sometimes 
described  as  cog-wheel  in  character.  While  this  latter  form  is  more  often 
detected  with  the  stethoscope,  it  may  be  occasionally  noticed  upon 
inspection  alone.  The  essential  characteristic  is  simply  an  interruption 
or  irregularity  of  the  inspiration. 

Another  distinct  type  of  respiration  is  witnessed  in  acute  conditions 
among  children.  There  is  displayed  a  striking  rapidity  of  the  respira- 
tions, together  with  an  audible  sound  upon  expiration.  The  child 
breathes  with  a  distinct  gi'unt  accompanying  the  expiratoiy  act.  This 
is  highly  significant  of  severe  capillary  bronchitis,  penumonia,  or  begin- 
ning Pott's  disease. 

A  form  of  respiration  known  as  stridulous  breathing  may  occur  in 
children  whenever  there  is  obstruction  or  marked  change  of  contour 
of  the  glottis  or  interior  of  the  larynx.  The  stridor  accompanies 
inspiration,  and  is  observed  in  edema  or  spasm  of  the  glottis,  false 
croup,  laryngeal  diphtheria,  and  whooping-cough.  The  slow  stertor- 
ous respiration  incident  to  profound  coma  has  no  remarkable  charac- 
teristics aside  from  its  snoring  quality  and  the  frequent  association  with 
cyanosis. 

Sighing  respiration  is  occasionally  oKserved  following  severe  hemor- 
rhage from  any  source,  although  it  is  perhaps  more  common  after 
pulmonary  hemorrhage. 

INSPECTION  OF  THE  CHEST 

It  is  unnecessary  to  describe  the  tyiiical  appearance  of  a  normal 
chest.  In  view  of  the  innumerable  (l(\iati(in-;  in  health  from  any 
conventional  type,  no  two  chests  may  be  s.iid  id  he  ]iiecisely  alike,  and 
the  variety  of  visible  conditions  presented  to  physicians  making  many 
examinations  is  almost  infinite.  Only  one  chest  in  four  has  been  found 
to  be  perfectly  symmetric. 

Clinical  inspection  of  the  chest  should  chiefly  include  attention  to 
the  size  and  form  of  the  thorax,  and  the  frcqviency  and  character  of 


INSPECTION 


159 


the  respiratory  movements.  In  most  cases  the  attention  of  the  examiner 
is  primarily  directed  to  the  size  of  the  chest. 

The  Size  and  Shape  of  the  Thorax. — There  is  a  great  diversity  in 
the  size  of  normal  chests.  Striking  differences  may  result  from  inheri- 
tance, occupation,  and  from  such  previous  conditions  of  health  as  the 
early  existence  of  rickets  and  adenoids.  The  same  peculiarities  in 
respect  to  size  are  often  noted  in  succeeding  generations. 

Remarkable  variations  are  also  exhibited  in  the  shape  of  the  thorax, 
no  two  chests  presenting  precisely  the  same  outward  appearance. 
Despite  innumerable  peculiarities  of  form,  chests  may  be  classified  as 
short  or  long,  broad  or  narrow,  and  deep  or  hollow.  Although  certain 
types  are   commonly  regarded  as   suggestive  of  intrathoracic  disease. 


Fig.  5.— Paral: 
feature  being 
the  sternum. 


■ig.  6.— Paralytic  and  long  type  of  chest, 
normal  area  of  cardiac  dulness.  The 
of   percussion    resonance   at   apices   are 


no  presumptive  conclusions  as  to  morb 
external  appearances.  A  characteristic 
paralytic  chest,  so  named  because  of  the 
pulmonary  tuberculosis.  If  the  soft  pMi' 
the  peculiar  effect  is  to  some  extent  cimili 


d  conditions  are  justified  by 
variety  is    the  phthisical  or 

fro()uency  of  association  with 
s  arc  coii^idciably  emaciated, 
L^i/;('ll.     'i'hc  thorax  i.-^  more  or 


less  flattened  anteroposteriorly,  with  sUght  increase  in  the  lateral  diam- 
eter, irrespective  of  the  length.  The  sternum  is  sunken  appreciably ;  the . 
sternal  ends  of  the  clavicles  are  apparently  pulled  downward;  the  neck 
appears  longer,  and  the  chin  more  sharply  defined  with  respect  to  the 
neck.     The  entire  bony  framework  of  the  chest  assumes  greater  promi- 


160 


PHYSICAL    SlCi-N 


nence,  the  ribs  being  more  conspicuous  and  the  intercostal  spaces  deeper 
and  usually  narrower.     In  the  l)ack  the  scapuhr  stand  out  broadly  from 


-The  short,  broad 


the  ribs,  giving  rise  to  a  suggestive  winged  appearance.     There  is  no 
material   deviation  from  normal   respiratory  movements  save  under 


I 


vhom   the  phytiical 


well  defined 


exertion  or  excitement,  when  they  become  noticeably  shallow  and  are 
somewhat  accelerated. 


(Mm 


-e 


INSPECTION 


It    should    lie  iM.riir    111    mill. I   th;it    .'i   w..ll-(l('lili.Ml 
l,,t    in,-,,]ll|.^,llM,.   NMlh   pri'lcrl     IumIiI,,  ,-,ih1  ^,1    o    t|, 


external    appearance.     The   prominence    of   the    scapula,  sometimes 
thnu'^lit  to  ho  charnctoriptif  of  pulmonary  phthi'^is,  mnA'  he  oliserved 

not    ii,riv,mciill\'  ,.v,.n   aiiioiiii   hcaltliv  aini  wll-ii.iuri-h<M|   individuals, 
riioii  ili,.,,ilu.rl.;Ni,l.  iiiaiivpaticiiis  with  advanced  ouliuoiian- involve- 


ment are  found  to  present  no  suggestion  of  a  winged  appearance  in  the 
scapular  region.  The  accompanying  cuts  are  of  interest  as  illustrating 
the  disproportion  between  the  visual  outlines  and  the  physical  findings. 


162  PHYSICAL    SIGNS 

Figs.  5  and  6  represent  typically  paralytic  chests,  although  there  is 
no  physical  evidence  of  tuliercle  deposit.  The  latter  is  an  excellent 
example  of  the  long  chest,  in  contrast  to  the  short  type  in  Fig.  7.  In 
Figs.  S,  9,  10,  11,  12,  13,  and  14  arc  shown  individuals  exhibiting  very 


Fig.  11. — Extensive  tubiMculi.n.  int,i  rh.n  <.f  l„.tli  Itint:~.  Left,  signs  of  consolidation  with 
moist  ri\les,  apex  to  base,  with  ,:i\ii\  ti-i  ni:it  hhi  Lmlii  iuiit;.  well-advanced  tuberculous  process 
at  apex,  front,  and  back.     ((.'(niipaT 

extensive  tuberculous  precesses,  notwithstanding  every  external  appear- 
ance of  perfect  health. 

In  th(>  <  iiijihiis,  inntiiiis  cliisi  ihi'iv  i^  an  iiicica-c  <if  all  the  diameters 
of  the  tliiirax.  -iii:iii- 1  iim  a  -laic  nf  |  icriiiaiiciit  iii-.|iii-at(iry  expansion. 
That  the  i-hcsl   i-  Uroailci-  and  il('c]icr  lliaii  iKH'inal  i-  u,-ually  recognized 


at  a  glance.  The  shoulders  and  clavicles  are  elevated,  and  the  neck 
appears  materially  shortened.  The  sternum  is  lifted  forward  and  up- 
ward, as  are  also  the  ribs,  w-hich  are  widely  separated,  moving  but  little 
upon  respiration.     In  .such  cases  protru.sion  of  the  abdomen  is  noticed 


INSPECTION 


163 


upon  inspiration.  The  rib-spaces  are  less  conspicuous  than  usual,  and 
in  exaggerated  types  may  be  slightly  bulging.  A  very  considerable 
degree  of  emphysema  may  exist  without  the  slightest  external  evidence 
of  the  so-called  l);aTcl  or  cinphysematous  type  of  chest.     It  is  even 


Fig.  13. — Tuberculous  infection,  entire  left  lung  from  apex  to  base,  with  cavity  formation  in  upper 
portion.     Also  active  involvement  right  apex  to  third  rib.      (Compare  with  radiograph,  Fig.  54,) 

found  in  the  so-callod  rachitic  and  iihthisical  varieties.  In  these  cases 
the  emphysema  ili'\clii|i.-  laii'  in  lilc.  when  ilic  iiony  framework  of  the 
chest  is  too  uuyicliliiiL;  incxhiliit  result iimdianucs  in  shape.  Examples 
of  emphy.sema  dc\cl(i]iiiii:  in  adult   lilc  arc  sIkiwii  in  Figs.  17  and  18. 


Fig.  14.— Well-de 


of  right  lung. 


In  the  rachitic  chest  the  anteroposterior  diameter  is  considerably 
increased,  particularly  in  the  upper  portion,  while  the  lateral  diameter 
at  the  base  is  materially  lessened.  The  sternum,  especially  in  its  upper 
portion,  often  becomes  very  prominent,  giving  lise  to  the  familiar  appear- 
ance of  "pigeon-breast."  The  lateral  retraction  at  the  bases  is  some- 
times marked,  and  is  attributed  to  the  previous  imperfect  entrance  of 


164  PHYSICAL    SIGNS 

;iir  to  these  parts,  and  to  the  effect  of  atmospheric  pressure.    Small  liony 


FJK.   13. — Representing 


enlargements  may  be  seen  or  felt  at  the  junction  of  the  ribs  with  the 
costal  cartilages.    This  line  of  beaded  projections  has  been  described  as 


Fig.  16.— RepresenI 


the  "rachitic  rosary."     In  some  cases  there  is  a  pronounced  depression 


INSPECTION 


165 


— Extensive  emphysema 
ith  moderate  tuberculous 
at  right  apex. 


of  the  lower  portion  of  the  sternum,  and  the  costal  cartilages  bend 
inward  and  backward  to  meet  the  ensiform  appendix  in  such  a  manner 


Fig.   19.— RemarkabI: 


as  to  suggest  the  name  of  "  funnel  jjreast."     A  rachitic  chest  with  funnel 
breast  is  shown  in  Figs.  20  and  21. 


S  PHYSICAL   SIGNS 

The  pictures  exhibited  to  illustrate  these  types  of  chests  will  afford 


Fig.  20. — Rachitic  type  of  chest  and  funnel  breast  in  a  patient  witii  moderate  tuberculous  involve 


a  clearer  conception  of  their  striking  peculiarities  than  any  further 


Fig.   21. — Sule  \'iew  of  preredinc  case. 

description.     It  should  be  repeatetl  that  in  many  instances  no  path- 


IXSPECTION 


167 


ologic  changes  are  founrl  within  the  chest,  despite  the  outward  mani- 
festations suggestive  of  disease,  and  vice  versa. 

Unilateral  Prominence  of  the  Chest. — An  entire  side  may  thus 
be  affected,  the  shoiildci-  being  elevated,  the  ribs  lifted  upward  and 
outward,  the  iutcrcd-ial  sj)aces  very  shallow-,  and  the  scapulae  pulled 
upward,  outward,  ami  Inrwa.rd. 

This  enlargeniciii  u(  mic  side  may  be  due  to  the  presence  either  of 
air  or  of  liquid  in  the  |il('ui;il  canity.  In  the  valvular  type  of  pneumo- 
tliorax  the  pleural  ovcidi-iciii  nm  is  extreme,  as  the  air  is  pumped  into 
tlie  cavity  witli  each  iuspiraliuu.  and  is  not  permitted  to  escape  upon 
expiration,  the  enlargement  of  the  affected  side  usually  becoming  well 
marked. 

In  small  plevu'al  effusions  it  is  often  impossilile  to  recognize  any 
apprccialilc  chaii-c  in  the  external  ajii-caiamc  of  the  rliest.  l)Ut  whoil 
tiic  (juaiitit}-  n|  Ii,|iii,l  niiilaiiicl  within  the  tliniacic  (•a\ity  is  large,  the 
careful  ol)ser\er  cannot  fail  to  distinguish  a  disparity  between  the  two 
siiles. 

Whenever  one  lung  is  compressed  by  effusion,  damaged  by  disease, 
bound  down  by  adhesions,  or  in  a  state  of  collapse,  the  other  lung  under- 
goes a  compensatory  emphy.sema.  Tlii-  -il|ip|elliellt;il  Wcilk  I'esultS  in  an 
increase  of  volume  and  in  a  correspnnil 

Unilateral  Retraction. — .An  entire 
dejiressed  and  more  or  le-<  dimi 
from  imperfect  develo|iiiieiit  follow iuLL  I 
cases  the  retraction  fs  a.-.-txiatctl 


chest,  as  well  as  of  the  cori-espondinir  side  of  the  face,  arm,  and  leg. 
Fig.  22  illustrates  this  retraction  \ei\-  well.  The  subject  is  a  boy 
nine  years  old,  with  extensive  tuberculous  infection  of  the  left  lung, 
who  recovered  after  the  lapse  of  two  years,  exhiliiting  marlved  fibrosis. 


168 


PHYSICAL    SIGNS 


The  retraction  of  the  left  side  i^  not  due  entirely  to  the  fibroid  change 
incident  to  the  arrest  of  the  tuberculous  process,  for  corresponding 
muscular  changes  are  present  in  the  left  side  of  the  face,  arm,  and 
leg.  Diminution  in  the  .size  of  the  chest  may  be  produced  in  adult  life 
by  reason  of  contraction  changes  in  the  lung  or  pleura  of  the  affected 
side.  Fig.  23  represents  the  retraction  of  the  left  .side  following  exten- 
sive fibrous  tissue  formation  and  supplementarj-  enlargement  of  the 
right. 

In  addition  to  changes  affecting  an  entire  side,  there  are  also  local- 
ized deviations  from  the  normal. 

Circximscribed  Prominences. — It  is  obvious  that  tumors  of  the 
soft  parts  m;iy  prdducc  changes  capable  of  ready  recognition.  The 
same  is  true  of  protuberances  upon  the  ribs  or  .sternum  resulting  from 
periostitis.     A  considerable  cardiac  enlargement,  especially  in  children, 


Fig.  23.— Left-sided  unilateral 


is  capalile  of  visual  detection,  as  is  also,  in  some  instances,  a  pericardial 
effusion,  an  aneurysm,  or  a  mediastinal  growth.  Pathologic  conditions 
in  the  lungs  or  pleura,  however,  rarely  give  rise  to  any  localized  external 
enlargements.  A  greatly  enlarged  li\er  or  spleen  rarely  may  be  recog- 
nized as  a  local  bulging. 

In  Fis:.  24  is  shown  an  instance  of  circumscribed  ]M'ominence  with 
accompanying  localized  depression  of  unknown  cause. 

Circumscribed  Depression. — The  most  important  cau.se  of  circum- 
scril'cd  (|cpi(.-si(in  i<  the  retraction  of  the  chest-wall  from  localized 
filirnid  rhanuc  The  most  common  location  is  either  above  or  below 
the  i'la\iclc.  Ill'  lidth,  A  cli>tinct  unilateral  depression  in  these  regions 
is  <|uiikly  ndtfd  l.y  tlic  i'\:iniiner,  and  is  immediately  suggestive  of  a 
prei•\i^tiu^  tul'ci-iiilnii<  ])i()rfss.  Localized  retraction  is  not  infrequent 
in  the  lateral  resion.  liut  is  not  always  susceptible  of  satisfactory  expla- 
nation. 


RESPIRATORY  MOVEMENTS 

It  has  been  stated  that  much  information  can  be  gained  with  refer- 
ence to  the  character  of  the  resi^iration  before  stripping  the  patient  for 


Fig.  25.— Hard  1, 
yeai-s  of  age.  The  c 
and  right  lung.     (Cci 


inspection.     It  is  difficult  at  times  to  foi-m  correct  impressions  regarding 
the  respiration  witli  the  patient  prepared  for  examination,  on  account 


of  nervousness  and  the  too  conscious  efforts  in  breathing.     It  is  true, 
however,  that  a  comparison  of  the  respiratoi y  movements  upon  the  two 


170  PHYSICAL    SIGN'S 

sides  is  maiiifostly  impossible  without  tlie  removal  of  the  clothing. 
Otherwise  (inc  i~  al-i,  unable  to  determine  whether  the  respiratory  move- 
ments are  iliaplna-iiiatic  or  costal  in  character.  In  male  adults  the 
respiratory  iuo\  eiueiits  bring  into  play  the  inferior  part  of  the  chest  and 
diaphragm.  In  females  the  i-espiration  is  frequently  confined  to  the 
uj)]3er  part  of  the  thorax — the  so-called  superior  costal  variety.  In 
children  the  liroatiniiir  is  usually  diaphragmatic.  A  costal  type  of  respi- 
ratidii  may  be  indurcd  in  adults  l.iy  any  cause  which  interferes  with  the 
descent  111  the  diaphragm  or  with  the  respiratory  function  of  the  lower 
portions  t)f  tlie  lung,  as  a  double  i^leurisy  with  effusion,  bilateral  retrac- 
tion of  the  bases,  or  exten^ive  tiliroid  change.  The  descent  of  the 
diaphragm  may  be  impeded  by  the  jiresence  of  a  large  quantity  of  ascitic 
fluid,  by  great  distention  of  the  abdomen  with  gas,  or  by  the  existence 
of  an  acute  peritonitis.  The  inferior  costal  or  diaphragmatic  respi- 
ratory movements  may  be  increased  by  causes  interfering  with  the 


expansion  of  the  upper  portions  of  the  lung.  While  the  movements  of 
respiration  should  occur  at  the  same  time  upon  both  sides,  and  be  per- 
fectly (Miual.  an  increased  (if  a  diminished  imilateral  expansion  is  not 
infre(|U('nt  in  the  presence  of  pathdlogic  conditions. 

Litten's  Phenomenon.  —This  interesting  sign  in  some  cases  is 
possessed  of  definite  diagnostic  value.  The  patient  is  placed  in  a  reclin- 
ing position,  with  the  feet  toward  the  window.  The  examiner  stands  at 
the  siile  of  the  ]iatient  and  observes  upon  full  inspiration  a  shadow- 
descending  from  the  seventh  to  the  ninth  ribs,  and  receding  upon  expira- 
tion. This  is  ]ii()(iuced  by  the  movement  of  the  diaphragm  in  con- 
nection with  tlie  descent  of  the  lung  into  Gerhardt's  complemental 
space.  It  is  not  capable  of  recognition  whenever  phj-sical  conditions 
prevent  the  fullest  exjiansion  of  the  lung.  It  cannot  be  detected  in 
pneumonia  of  the  lower  lobe,  moderate  pleural  effusions  or  pneumo- 
thorax, firm  pleural  adhesions,  severe  peritonitis,  or  ascites.     Whenever 


INSPECTION  171 

the  descent  of  the  diaphragm  is  not  interfered  with,  the  Litten  phe- 
nomenon is  of  value  as  aiding  in  the  differentiation  of  enlarged  liver  and 
pleural  effusion.  It  is  also  of  aid  in  some  cases  in  the  diagnosis  of  incip- 
ient apical  involvement,  as  will  be  further  discussed  under  Diagnosis. 

CARDIOVASCULAR  CHANGES 

Any  extended  consideration  of  heart  and  circulatory  conditions  is 
entirely  without  the  scope  of  this  book.  There  exists,  however,  so  inti- 
mate and  reciprocal  a  relation  between  pulmonary  diseases  and  cardio- 
\-ascular  disturbances  that  brief  reference  to  associated  heart  changes 
is  desirable. 

The  data  to  be  obtained  upon  inspccCKin  as  regards  the  heart  and 
circulation  are  always  of  much  intcivM  In  -oiue  instances  but  little 
of  practical  value  is  detected,  even  altci  a  scaidiing  inspection.  Often 
the  facts  thus  deri\e(l  bccdnic  of  imjiortance  only  when  confirmed  by 
the  results  of  palpatimi  ami  pci-cussion. 

For  successful  ius|ic(ti(in  with  reference  to  the  heart  or  circulation 
a  careful  technic  imist  be  employed.  The  physician  nuist  l)e  thoroughly 
familiar  with  the  iMis^iMi'  caidiac  and  va.sculai-  cliaiiiics.  and  be  iircp.ii-cd 
to  watch  for  tlit-ii'  appcaiance.  Upon  ins]>i'it  ion  with  re,t;aid  tn  pul- 
monary conditions  tlie  patient  is  usuall}'  oli-cixcd  by  the  examiner 
from  a  distance  in  order  to  afford  oppml  uiiii  y  im'  a  comparison  of  the 
two  sides  of  the  chest.  When  noting  canliac  cumiilications,  however, 
the  physician  must  stand  much  neai-cr  the  patient,  and  the  inspection 
becomes  a  matter  of  closer  detail.  The  inspectidii  sliould  be  made  with 
the  patient  both  in  the  upright  and  in  the  rcilinia^  posture.  The 
exaniiiiei-  slnnild  take  (■(iguizaiice  ol'  clian'je-  leleialile  to  the  precordia 
as  u  \vli<i|e.  the  apex-beal,  ami  t  he  e|  H-a  I  ric  ic-i(in.  The  neck  should 
be  examined  in  (ii'dei'  I"  deiermine  I  lie  pre-enee  ill'  absence  of  arterial 
thn.l,l,m-(irvem,uspulsali.in:tlieann<.  I..i- eviden.'e  <if  bi-achial  arterio- 
.scier.isis:  the  alMhuneli  and  rhesi  Heal'  the  .al  tacliinent  .if  the  .liaphragm, 
q.illaivdilatatmn,  .and  the  lips,  iui-  the  detection 


of  capillary  pulsation. 

CHANGES  RECOGNIZED  IN  THE  PRECORDIA  AS  A  WHOLE 

Reference  has  been  made  to  the  circumscribed  bulging  of  the 
ribs  in  the  precordial  region  as  a  result  of  lickets,  cardiac  hypertrophy, 
and  pericarditis  with  effusion  in  children.  Protrusion  of  the  precordial 
region  due  to  these  causes  is  not  associated  with  \isiliie  nniscular  move- 
ments of  cardiac  origin.  There  may  be  oliser\ed  at  times  a  distinct 
rhythmic  rise  and  fall  of  the  soft  i)arts,  between  the  second  and  fourth 
or  fifth  ribs.  Tliis  may  be  noted  as  .a  liea\inu  impulse  synchronous  with 
the  heart's  action,  or  as  a  peristaltic  \\a\'e  or  undulation.  Visible  pre- 
cordial pulsation  may  be  explained  by  the  following  general  causes,  i.  e., 
exaggerated  heart  contractions  in  thin,  nervous  people  suffering  from 
so-called  cardiac  neuroses,  muscular  effort,  or  excitement  (though  rare), 
exophthalmic  goiter,  simple  cardiac  hypertrophy  with  or  without  aortic 
regurgitation,  and  occasional  arteriosclerosis. 

In  addition  to  the  above  conditions,  which  relate  particularly  to 
the  heart  and  circulation,  other  causes  may  exist  independent  of  cardio- 
vascular changes.     It  is  well  known  that  in  profound  anemic 


172  PHYSICAL    SIGNS 

with  deficient  aeration  of  the  blood  the  respiratory  movements  are 
shallow  and  rapid,  \^'ith  cUminished  expansion  of  the  lung  a  larger 
portion  of  the  heart  becomes  denuded  of  its  pulmonary  covering  and 
renders  possible,  at  times,  visible  pulsations  in  the  precordia.  In  the 
same  way  shrinkage  due  to  left-sided  fibrous  tissue  proliferation  operates 
to  uncover  a  larger  portion  of  the  heart,  as  well  as  to  effect  its  chsplace- 
ment. 

CHANGES    RECOGNIZED   IN   THE    CARDIAC    IMPULSE   AT   THE   APEX 

The  apex-beat  is  not  produced  by  the  very  apex  of  the  heart.  The 
latter  is  situated  about  three-quarters  of  an  inch  to  the  left  of  what  is 
recognized  visually  as  the  apex-beat.  The  anatomic  apex  is  covered 
by  a  projection  of  lung  called  the  lingula  pulmoualis.  The  visible 
apex-beat  is  produced  by  the  contraction  of  the  lower  portion  of  the 
right  ventricle  as  it  strikes  the  wall  of  the  chest.  The  location  of  the 
apex-beat  is  described  as  an  area  about  three-quarters  of  an  inch  square, 
between  the  fifth  and  sixth  ribs,  a  little  within  the  nipple.  In  this 
position  there  may  often  be  seen  a  rise  and  fall  of  the  chest-wall  with 
each  pulsation  of  the  heart. 

In  corpulent  individuals,  and  particularly  in  females  with  large 
mammse,  it  is  frequently  impossible  to  detect  any  visible  apex-beat 
whatever.  In  children  this  is  found  higher, — sometimes  in  the  fourth 
interspace, — while  in  the  other  extreme  of  life  it  may  be  depressed  as 
far  as  the  i=ixth.  Tho  hoart  hpin;;-  attached  at  its  base  solely  to  the  great 
vessels,  mayb.'  iiii.mincd  t(i  .^wiiii;  in  -om:'  cxtj-.it  as  upon  a  pivot.  This 
permitsacoii-idiTaMciliftciviirr  in  tin- luratinii  c.r  the  apex  upon  changes 
in  the  positiun  o!  the  imlividual  and  dthcr  i-aii-r-.  Cnnfiauration  of  the 
thorax  may  also  have  an  inila;-nr(.  in  chaiiiiiim'  it-  iio^ition. 

In  rachitic  chest-.  e>i>iM  ially  with  pidt riwioii  nf  t!ie  sternum,  the  apex 
may  be  fotuid  di^placrd  -liiihlly  upward  and  to  the  right  of  its  normal 
positiiin.  As  a  result  (if  a--i>iiatrii  jiathdld^ic  concUtions  the  apex  may 
lie  dislocated  to  the  ri^ht  (ir  left,  iipwaid  or  downward.  The  morbid 
chanij,C's  sutficient  to  ]ii()dii'e  these  results  may  exist  in  the  heart  itself, 
in  the  ])eriranliiun   in  the  Inn-s,  in  the  pleura,  arteries,  and  kidneys. 

The  im]iortant  chanm-^  in  the  heart  sufficient  to  alter  the  location 
of  till'  ajicK-l  ii'at  arc  ihieHy  hypertrophy  or  dilatation. 

llvpfitin|ili\  ,,i'  the  right  or  left  ventricle  may  displace  the  apex- 
beat  to  the  h'it  and  -liirhtly  downward.  If  associated  with  arteriosclero- 
sis, esiieiially  in  aged  people,  the  downward  displacement  is  considerably 
increased. 

In  ]3ericarditis  with  effusion  the  apex  is  lifted  and  displaced  slightly 
to  the  left. 

Changes  in  the  lungs  may  suffice  to  obliterate  the  visible  apex- 
lieat.  to  displace  it  downward  or  to  either  side.  It  may  be  obscured  as 
a  result  of  pronounced  emphysema,  the  increased  volume  of  lung  inter- 
posing such  a  layer  lietween  the  right  ventricle  and  the  chest-wall  as 
to  ]irec'hide  an>-  \i-ilile  inipulse.  Sometimes  the  apex  is  depressed  in 
emphysema.  The  cardiac  impulse  may  be  displaced  either  to  the  right 
or  to  the  left,  bj^  virtue  of  fibroid  contractions,  the  heart  being  pulled 
usually  en  masse,  but  occasionally  with  a  con.spicuous  change  in  the 
position  of  the  apex. 

Pleurisy  with  effusion,  on  the  other  hand,  pushes  the  heart  away 


INSPECTION  173 

from  the  affected  side,  often  producing  a  considerable  change  in  the 
location  of  the  apex-beat.  In  left-sided  pleurisies  the  apex  is  displaced 
to  the  right.  Not  infrequently  in  pleurisies  of  the  right  side  it  is 
forced  to  the  left  and  somewhat  elevated.  In  i)neumothorax  also  the 
heart  is  pushed  peiveptibl\-  lowai'd  the  uiiafrcctcd  .<iilc.  I  h,i\c  ..rra- 
sionallv  found  the  ai)ex  in  a  lelt-iidcd  pncuniothoiax  in  the  iiiiinc.riale 
vicinity  of  the  ri-ht  inpiilc.  The  apex  of  the  liearl  may  be  displaced 
upward  by  changes  in  llie  abdominal  ca\-ily  resulting  in  an  elevation 
of  the  (haphraiiin.  /.  ,..  exces.-^ive  distent  i,.n  liom  .eas  or  ascitic  fluid. 

A  rclraclioii  of  the  <'he,-t-\vall  r-;  Miinetinies  -een  at  the  site  of  the  apex- 
beat.  This  IS  due  prmcipaily  to  a.llieM\e  pleui.ipeiicarditis.  The 
adhesions  between  the  pericardiinn  and  plenia  |ieiinit  a  drawing  in 
of  the  chest-wall  during  sysi(jle,  with  occa.-^ionaily  a  visible  rebound 
during  diastole. 

EPIGASTRIC  PULSATION 

Visible  pulsation  in  the  epigastrium  ma>-  lie  noted  under  certtiin 
conditions.  Not  infrequently  this  is  obser\ed  in  thiii  persons  and  in 
tho.se  of  decided  nervous  temperament.  In  such  ca^es  the  jjiilsation 
is  de\'oid  of  an\-  ])athol(mic  si'jnilicance.  It  may  be  present  in  aneurysm 
of  the  abdoniiiial  aorta,  a  cciniparatively  rare  condition.  The  pulsation 
may  be  traiismitted  throimh  a  >o|i(l  neoplasm  affecting  the  pyloric  end 
of  the  stomach  or  the  pancreas,  and  also  tlii()UL;li  the  left  lobe  of  the  liver. 
It  may  exist  on  account  of  hy]>ert  mi'liy  oi  the  liiiht  ventricle.  Usually 
it  is  easy  to  ascertain  the  preta-e  i  auc  of  e]u.ua,stric  pulsation  through 
the  process  of  exclusion. 

VISIBLE   CHANGES   IN   THE   NECK 

Throbbing  of  the  carotids  is  easily  recognized.  It  is  usually  a-^so- 
ciated  with  hypertrophy  of  the  left  ventricle  in  connection  with  aortic 
regurgitation,  producinc'  an  exaggeratorl  pubation  also  in  the  Ijrachial, 
railial.  and  tetnpdial  icL'icii  ,  Imrea-vil  arterial  pulsation  is  noted 
in  exophllialniir  -(.iter,  ill  -tati-  <ii'  artiaial  excitement,  and  as  a  result 
oi'  aiierio^clero-i--  \eii(iii-  |  ml- at  a  ni  dl  i-i'r\-etl  in  the  neck  is  of  com- 
liaralivelv  little  H^iiilic.a nee  ii'  jire;. \M ,,|ic  in  time.  If  systolii'.  if  is 
indicati\-e  oi'  tri(aha.id  re-iii^il  at  ion.      When  exceedingly  liiiht  jiressiire 

in  the  lower  part  n\  the  hitI,.  and  inore  IVei|uentl\-  upon  the  riuiit  than 
upon  the  left,  the  pnl-aticn  imniediafelx^  ceai-  pi<.\ided  it  i-  imrely 
venous  in  origin.  11.  Ii(i\\e\er.  t  he  pel- a  lion  i-^  arterial  in  character,  liiiht 
liressure  will  not  caii-e  it-:  di- appearance.  If  the  \'ein  is  stroked  from 
below  uiiwanl  and   iniiiiediatel\-   1111-^  fidin   below,  the  e\-idence  is  con- 

\'aluab|e  dat.a  iicix  I  .e  nl.i;iiii(.,|  Irnin  in  peciimi  of  the  arms 
to  ascertain  the  e\i  t eiice  nf  .a ri erii i-  cliao  i  The  arteries  are  Sometimes 
tortuous  .a  lid  excee.hn^h  pr ineiit.  with  ni.arked  iT'idit  v  of  the  walls. 

The  siiperliiaal    Mo<h|-V( ■]-:  ..f  the  alMl.iineii    iiiav  likewi-c  be  .-^.■eu 

to  stand  out  pr(,iiiineiitl\-  iipiin  tlie.<kiii  a-^  ,a  result  of  cib- 1  nict  im,.  .More 
frefiuently  there  ,aiv  nl.-,a\ed  -^inall  capillar\-  dil:itatiun<  which  may 
extend  like  a  bdw  aia-n-  th,,  entire  front  near  the  at  tachnieiit  of  the 
diaphragm.  No  -ati- tactoiw  explanation  ha-^  been  oflere(|  tor  their 
occurrence.  It  has  not  been  found  in  constant  association  with  recog- 
nized cardiac  involvement. 


174  PHYSICAL    SIGNS 

While  capillary  pulsation,  usually  occurring  as  a  result  of  aortic 
regurgitation,  is  sometimes  capable  of  recognition  upon  casual  inspec- 
tion, it  muj'  lie  ea,sily  tletected  either  upon  the  lips  or  under  the  finger- 
nails with  slight  pressure. 


CHAPTER   XXX 
PALPATION 


Palpation,  or  the  cniitloyment  of  the  sense  of  touch,  has  been  too 
frequently  rciinrdcil  as  of  little  value  in  the  physical  examination  of 
the  chest.  .Mtlioiinli.  iicrhaiis.  of  less  importance  than  some  of  the 
otlu'i'  iiiciIkmIs.  it  i-^.  iii'NiTiliclcss.  (if  cxi-ccilhi^j:  benefit  to  the  examiner 
in  nian\-  in^i.iiicc-.  \cl;Icci  in  iiiili/.c  iliis  iiictliod  of  examination 
often  ciii.iiN  f.ailiiiv  In  ivn i'_:m/,,.  plix  .-^ical  cciiiditioiis,  the  presence  of 
whicli  wiuild  (iiliciw  i-c  lie  c.isily  iletected.  As  u.sed  for  the  diagnosis 
of  rcs])iiat(ii  y  i  li-;c.i-(-.  ii  iii.i\-  be  said,  in  a  general  way,  to  confirm  the 
results  of  inspect  ion,  Mncli  (if  the  information  afforded  by  the  sense 
of  sight  can  alsd  be  nlii  aineilhy  a  care  fully  trained  sense  of  touch.  This 
I  have  repeafe(lly  witnessed  in  observing  the  work  of  a  cUstinguished 
physician  (lep;i\(Ml  oi'  his  si^ht.  In  some  instances  certain  data  obtained 
by  inspection  are  so  detinite  and  exact  as  scarcely  to  require  the  employ- 
ment of  palp.ition  for  their  verification.  Through  its  employment  in 
speci.il  instances,  however,  information  may  be  acquired  of  a  more 
positive  ;uid  accurate  character  than  is  possible  from  inspection.  For 
example,  the  peculiar  flattening  of  the  bony  thorax  incident  to  the 
phthisical  chest  may  sometimes  be  overlooked  upon  inspection  on 
account  of  the  thickness  of  overlying  soft  parts.  Upon  palpation  of  the 
upper  lateral  regions  the  prominent  outward  arching  of  the  ribs 
is  immeiliately  noticed,  and  attention  drawn  to  the  flattening  of  the 
chest.  As  a  rule,  palpation  of  the  thorax,  with  a  view  to  ascertaining 
its  shape,  size,  and  the  character  of  the  respiratory  movements,  is 
entirely  superfluous  if  preceded  by  systematic  inspection. 

The  chief  value  of  this  method  of  physical  examination  is  to  elicit 
vocal  fremitus. 

The  hands,  which  otight  not  to  be  unduly  cold,  should  be  placed 
upon  symnietiic  ]iai(s  of  tlie  chest.  It  is  not  necessary  that  much  pres- 
sure be  exeiteil.  .1  Iii:lii  touch  beini;  ordinaiily  all  tiiat  is  required.  In 
some  instances,  ho\\c\ci\  it  is  well  to  use  inoderalel}-  firm  pressure  when 
examining  for  vocal  fremitus.  (;eneiall\  <peakinu.  tiie  palm  of  the  entire 
hand  should  be  laid  upon  the  chest,  caic  beiiiLj  taken  that  the  fingers 
are  not  peiniitted  to  rest  in  the  inieicostal  sp.aces.  When  examining 
a  small  area  the  tips  of  the  fingers  lightly  pressed  against  the  chest- 
wall  yield  the  best  results. 

vcx:al  fremitus 

This  sign,  sometimes  called  tactile  fremitus,  refers  to  a  distinct  vibra- 
tion which  is  imparted  to  the  htuid  laid  upon  the  chest  during  phonation. 
The  vibrations  emanating  from  the  vocal  bands  are  conducted  to  the 


PALPATION  175 

wall  of  the  thorax  by  virtue  of  the  column  of  air  in  the  trachea  and 
bronchial  tubes,  augmented  by  solid  contiguous  parts. 

Vocal  fremitus  is  best  appreciated  when  the  patient  is  instructed 
to  repeat  numerals,  harshly  and  in  a  low  pitch.  In  comparing  different 
parts  of  the  chest  care  should  be  taken  that  the  spoken  voice  con- 
forms to  the  same  monotone  at  all  times  and  to  the  same  degree  of 
loudness.  The  vibration  is  much  greater  in  males  than  in  females — in 
fact,  it  is  often  incapal)le  of  rccdnniiioii  aiiKni-  the  latter.  It  is  less 
pronounced  in  children  than  in  adults,  ami  much  greater  in  those  who 
have  deep  l)ass  voices  and  thin  chests.  It  is  diminished  by  thickness 
of  the  soft  parts,  resulting  from  excessive  muscular  development  or 
thick  layers  of  adipose  tissue. 

The  \-ocal  fremitus  varies  in  difforont  parts  of  the  chest,  and  there 
is  a  nortiiiil  (li.-<jiiiril i/  lie)  ween  tlie  \  ilir,'itii)n  elicited  at  the  two  apices. 
It  is  marked  at  the  apex.  Ih.iIl  al»>\e:iml  below  the  clavicle,  and  in  both 
lateral  regions  cil'  the  chesl .  pait  i(uiail\  in  the  upper  portions.  It  is 
also  ]iic>iiiiimce(l  in  the  interscapular  ic^iims.  whih'  at  the  bases,  over  the 
scapula',  and  in  the  regicm  <il'  the  heart,  it  i.--  appreciably  diminished.  The 
jremitujs  if;  distinctly  more  inurkcd  at  the  riyhl  upc.v  than  at  the  left,  both 
in  front  and  back,  and  more  in  the  right  interscapular  region  than  in  the 
left. 

In  disease  the  vocal  fremitus  may  be  greatly  increased,  diminished, 
or  entirely  absent. 

Speaking  broadly,  it  may  be  said  to  be  increased  whenever  there  is 
within  the  huig  a  gTeater  relative  amount  of  solid  to  air  than  normal. 
Thus,  in  consolidatinn  of  the  lung  from  any  cause,  as  pneumonia 
or  lubercuhisis,  the  \iliial(iry  phenomenon  is  distinctly  exaggerated. 
Whenever  the  jiulinonary  tissue  is  cnmpiTssed  by  virtue  of  a  coexist- 
ing pleural  etTusion.  the  vibiatidu  is  cciri-esp(in(iin,i;ly  affected.  It  is 
increased  over  a  large  snpeilicial  pulm(inar\-  ca\it\-  surrounded  by 
indurated  lung,  and  al-n  in  a  icceiit  cDiiipensatoiy  emphysema  because 
of  the  inci-easi.(l  ti-nsi.m  of  the  pulmi.nai'v  tissues. 

The  vocal  frenutus  ma\'  be  ili iiiiiiish< d  oi'  nhsiiit  on  account  of  any 
condition  interfering  with  the  transmission  of  the  vibration  through 
the  column  of  air,  or  the  interposition  of  a  medium  through  which  it 
must  pass  before  reaching  the  chest-wall . 

Among  the  former  causes  may  be  mentioned  chiefly  the  occlusion 
of  a  primary  bronchus  from  secretions,  from  pressure  of  mediastinal 
glands,  aneurysm,  or  new-growths,  and  the  collapse  of  lung  in  pneu- 
mothorax, in  any  of  these  conditions  the  vocal  fremitus  may  be 
diminished  or  entirely  absent,  although  peii-nssion  changes  may  not  be 
pronounced.  The  re.spiratory  sounds,  like  the  \dcal  fremitus,  may  be 
le.s,sened  or  absent  in  occlusion  of  the  bronchus  and  in  the  closed  or 
valvular  types  of  pneumothoi'ax.  In  very  rare  instances  the  fremitus 
is  cUminished  in  complete  solidification  of  lung. 

The  lessening  of  vocal  fremitus  in  pneumothorax  is  due  to  the  utter 
collap.se  of  the  lung,  with  consequent  closure  of  the  bronchus  and  oblit- 
eration of  the  air  column,  and  to  the  interposition  of  a  layer  of  air 
between  the  lung  and  the  chest-wall. 

The  vibrations  are  olistriicte(l  through  the  intervention  of  another 
medium,  as  in  pleurisy  witii  effusiim.  and  in  the  presence  of  pleural  thick- 
enings, contractions,  or  plastic  exudations.  Aclhesions  may  or  may  not 
facilitate  the  conduction  of  vibration  in  these  cases. 


176  PHYSICAL    SIGNS 

In  pleurisy  with  effusion  the  liquid  does  not  remain  at  the  base  of 
the  pleural  cavity  with  its  upper  surface  corresponding  to  a  horizontal 
plane,  l)ut  is  molded  to  a  certain  extent  around  the  lung,  between  it  and 
the  chest-wall.  According  to  the  extent  and  size  of  the  effusion,  the 
vocal  fremitus  is  (hnuiu^hed  or  cntiicly  absent. 

In  extensive  |ilcnral  t  liickciiiim  with  adhesions  the  vibrations  are 
transmitted  less  readily  un  acrount  of  the  iuterijosition  of  solid  media. 

PALPABLE  RHONCHI;  PLEURAL  AND  PERICARDIAL  FRICTION- 
SOUNDS 

Although  vocal  fremitus  is  the  principal  physical  sign  capable  of 
recoKnition  bv  palpation,  it  is  rather  interesting  to  note  the  occasional 
detertiui,  ..|-  I'lr.mcliial  rale-,  a-  well  as  pleural  and  pei-i.',a  nlial  friction- 
soui!.l   ,  \<y  the  -^eii^:e  (il  luih^li.      'I'iie  (lr\-.  Iiaidi  lii.iiiclii  iiia\-  Miinetimes 

A|ipre(  iaMe  \iliiai(iry  impressions  may  be  conveyed  to  the  hand  as 
friction  iiilis  emanating  from  the  jileura  or  pericardium,  but  the  detec- 
tion of  these  sounds  is  com])arati\-e|>-  rare  upon  palpation,  and  their 
recognition  perfectly  simple  upnu  auscultation. 

Brief  mention  should  be  made  ((lucerniag  the  importance  of  palpa- 
tion in  examination  of  the  heart.  The  position  of  the  apex-beat  may 
be  detected  in  many  instances  when  impossible  of  recognition  by  the 
sense  of  sight,  and  at  the  same  time  valuable  information  may  be  derived 
as  to  the  cli.aracter  of  the  cardiac  iiii])nlse. 

In  deteiiiiiiiiii-  the  -i/.e  of  the  heart,  the  results  of  palpation  are 
often  more  ilelmiie  and  })ositi\-e  in  character  than  those  of  percussion. 
The  tympanitic  icsonance  of  the  stomach  is  often  transmitted  upward 
and  to  the  left,  iiiiei-fering  with  cardiac  percussion.  By  feeling  care- 
fully with  the  tii>s  of  the  fingers  at  the  left  of  the  heart's  apex  to  the 
furtliest  point  v\here  any  cardia-  niox-etiient  is  recognized,  an  approxi- 
mate estimate  can  l:)e  made  of  the  left  cardiac  boundary.  The  presence 
or  absence  of  a  thrill  is  also  ascertai'cd  with  the  fingers  laid  against 
the  precordial  region.  This  sign  is  usually  obtained  at  the  apex  and 
over  the  aortic  valve,  and  has  been  described  as  similar  to  the  sensation 
felt  with  the  hand  placed  upon  the  throat  of  a  purring  cat.  The  thrill 
is  usually  presystolic  at  the  apex,  but  in  rare  instances  may  be  sy,stolic 
in  time. 

PaljKition  of  the  blood-vessels  is  also  important.  By  this  means 
delinite  infoimaiion  is  'jained  respecting  the  visible  pulsations  in  the 
neck,  wlieiliei'  of  \eiioii    (,r  ai-terial  origin. 

The  ilr_:ree  of  ariia  lo-ilcro  is  of  the  brachial  arteries  is  appreciated 

arlrrv    i      oi    cMivme   N;,lne    in    noinn:   llie    rate,    rlivtliin,   tensi,ni,   and 
cOlupr.-Ml.ility  of  tl,e  pulse,  and  the  character  of  the  arterial  wall. 


PERCUSSION 


CHAPTER   XXXI 
PERCUSSION 


While  inspection  relates  to  the  diagnosis  of  physical  conditions 
through  the  sense  of  sight,  and  palpation  through  the  touch,  percussion 
refers  to  the  act  of  tapping  the  chest,  thus  setting  up  vibrations  which 
may  be  appreciated  by  the  examiner  through  the  sense  of  hearing. 
Nothing  can  so  signally  characterize  the  skill  of  the  physician  in  phy- 
sical diagnosis  as  ability  to  perform  percussion.  Success  can  be 
obtained  only  by  a  thorough  acquaintance  with  the  normal  percussion 
boundaries  of  the  various  organs  and  by  the  unvarying  observation  of 
a  careful  technic.  Failure  is  accounted  for  by  lack  of  familiarity 
with  the  anatomy  of  the  thorax  and  its  contents,  as  well  as  by 
neglect  to  adhere  rigidly  to  prescribed  methods.  A  perfect  knowledge 
of  the  principles  of  percussion  as  applied  to  the  normal  chest  is  a 
necessary  preliminary  to  any  consideration  of  abnormal  conditions. 
Despite  familiarity  with  the  theory  of  percussion,  conspicuous  skill  can 
be  secured  only  by  continued  practice.  It  is  the  intelligent  technic, 
perfected  by  long  experience,  which  serves  to  bring  forth  the  sound 
vibrations,  and  enables  the  physician  to  recognize  important  analytic 
differences  and  to  acquire  confidence  in  the  results  of  his  examination. 
It  is  not  so  much  the  possession  of  a  keen  musical  ear  which  some  regard 
.as  a  sine  qua  non,  as  a  well-trained  sense  of  hearing  with  relation  to  the 
recognition  of  a  few  simple  elements  of  sound. 

The  sound  elicited  by  percussion  may  be  regarded  as  either  resonant 
or  non-resonant.  Whenever  the  air  contained  within  aerated  bodies 
is  set  in  vibration  by  percussion,  the  sound  produced  is  always  resonant 
in  character.  If  percussion  is  'practised  upon  solid  bodies,  the  sound 
is  at  once  recognized  as  non-resonant,  and  is  described  as  flat.  Flatness, 
therefore,  should  not  be  included  as  one  of  the  varieties  of  resonance. 
Organs  containing  but  little  air  may  give  rise  to  a  diminished  resonance 
which  is  called  dulness. 

All  resonant  sounds  may  be  classed  with  reference  to  four  important 
characteristics — inten.sity,  pitch,  quality,  and  duration. 

Intensity  refers  to  the  extent  or  volume  of  the  vibrations,  and  is 
■commonly  classified  as  loud  or  faint.  This  varies  directly  with  the 
force  of  the  blow,  the  thickness  of  the  intervening  soft  parts,  and  the 
volume  of  the  underlying  lung. 

If  the  percussion  blow  is  gentle,  the  vibratory  intensity  may  be 
slight  or  inappreciable,  while  very  powerful  percussion  tends  to  obscure 
the  resonance  by  inducing  vibrations  in  distant  parts  of  the  organ. 
A  stronger  blow  is  necessary  to  elicit  audible  resonance  in  some  chests 
than  in  others.  It  must  follow  that  the  force  of  the  percussion  must 
be  adjusted  in  all  cases  to  the  conditions  presented  at  the  time  of  the 
examination. 

It  is  obvious  that  the  intensity  must  vary  with  the  thickness  of  the 
soft  parts  overlying  the  aerated  lung.  Well-marked  muscular  develop- 
ment and  thick  layers  of  adipose  tissue  diminish  the  loudness  of  the 
tone  and  require  somewhat  harder  percussion.  A  lessened  intensity 
is  noted  over  the  scapulae  because  of  the  intervening  bony  formation 
12 


178  PHYSICAL    SIGNS 

and  the  thick  muscles  of  the  back.  Percussion,  if  attempted  ovei"  a 
large  mammary  gland,  is  usually  unsatisfactory.  On  the  other  hand, 
gentle  percussion  upon  the  thin  chests  of  emaciated  incUviduals  and  in 
children  is  sufficient  to  awaken  resonance  of  decided  intensit}'. 

Other  things  being  equal,  the  intensit}'  is  increased  in  proportion 
to  the  greater  volume  of  lung  on  account  of  the  larger  amount  of  con- 
tained air.  For  this  reason  the  resonance  is  more  intense  below  the 
clavicles  than  above. 

Pitch  refers  to  the  length  of  the  vibrations,  and  is  described  as  low- 
when  the  vibrations  are  long,  and  high  when  they  are  short.  This  is 
the  most  important  eleyncnt  of  sound  from  a  diagnostic  standpoint,  and  is 
often  a  source  of  great  confusion  to  studc7its.  It  should  be  borne  in  mind 
that  pitch  bears  no  absolute  relation  to  intensity.  Sounds  may  be  loud 
or  faint,  and  )-et  have  precisely  the  same  pitch. 

The  lowness  or  highness  of  pitch  is,  of  course,  pureh'^  relative.  The 
pitch  obtained  in  aU  pathologic  states  within  the  thorax  is  higher  than 
in  a  normal  chest.  For  the  sake  of  convenience,  the  pitch  in  health 
should  be  described  as  relatively  low.  As  there  takes  place  a  greater 
relative  amount  of  solid  to  air  in  a  given  portion,  the  resonance  becomes 
dull  and  higher  in  pitch.  The  pitch  may  also  be  elevated  upon  per- 
cussion over  bodies  of  air,  but  this  is  accompanied  by  change  in  quality. 

Difficulty  is  usually  foimd  in  descrilnng  precisely  what  is  meant 
by  the  qualiti/  of  a  sound.  It  refers  to  a  peculiar  character  of  the  vibra- 
tions, dependent  upon  the  precise  construction  of  the  air-containing 
body  in  or  from  which  the  sound  is  produced.  Thus  the  quality  of  the 
sound  produced  by  the  flute,  the  piano,  the  violin,  etc.,  varies  according 
to  the  detailed  construction  of  the  instrument  from  which  the  sound 
is  emitted.  The  quality  of  the  sound  from  a  piano,  for  instance,  cannot 
adequately  be  described  to  a  person  who  has  never  heard  it,  yet  one  who 
has  been  familiar,  even  to  a  slight  degi-ee,  with  musical  instruments  can 
recognize  instantly  the  sounds  produced  by  a  piano  or  other  instrument 
in  an  adjacent  room,  not  because  of  their  intensity  or  their  pitch,  but 
wholly  as  a  result  of  their  peculiar  incUvidual  quality.  The  pitch  may 
be  high  or  low,  the  sound  may  be  loud  or  faint,  and  yet  no  difficidty  is 
experienced  in  differentiating  its  quality  or  character.  As  the  quality 
of  tones  emitted  by  musical  instruments  is  dependent  entirely  upon 
peculiarities  of  structure,  .so  the  character  of  the  sound  obtained 
by  percussion  of  the  normal  chest  is  incident  to  the  anatomic  con- 
struction of  the  air-containing  organs.  The  term  "  vesicular  resonance  " 
naturally  has  been  given  to  the  vibrations  emanating  from  the  air- 
vesicles  of  the  normal  lung.  This  is  to  be  chstinguished  from  the  so- 
called  "  tympanitic  resonance  "  obtained  upon  percussion  over  large 
bodies  of  air.  AU  resonance  is  either  vesicular  or  tympanitic  in  quality. 
As  the  quality  changes  from  vesicular  to  tympanitic,  the  pitch  is  corre- 
spondingly higher. 

In  comparison  with  intensity,  pitch,  and  quality,  duration  is  of  but 
slight  importance  as  an  element  of  percussion  resonance,  although  of 
great  value  in  the  analysis  of  auscultatory  sounds.  Generally  speaking, 
the  duration  of  the  vibrations  increases  with  the  intensity  and  dimin- 
ishes with  the  elevation  of  pitch. 

To  elicit  intelligent  percussion  resonance  certain  methods  of  pro- 
cedure should  invariablv  be  followed. 


PERCUSSION  179 


RULES  FOR  THE  PRACTICE  OF  PERCUSSION   RELATING  TO 
THE   PATIENT  AND  TO   THE  EXAMINER 

Rules  for  the  Patient. — The  patient,  whether  sitting  or  standing, 
slioulcl  be  in  an  attitiule  of  repose.  The  shoulders  should  not  be  thrown 
too  far  back,  and  the  muscles  of  the  neck  or  chest  should  not  be  put  in  a 
position  of  undue  tension.  It  is  necessary  that  the  shoulders  and  arms 
be  held  symmetrically.  The  head  should  not  Ije  inclined  to  either  side, 
and  the  face  should  be  directed  straight  ahead.  It  is  sometimes  per- 
missible for  the  face  to  be  turned  slightly  to  one  side  while  percussing 
at  the  apex,  particularly  if  there  is  noticeable  retraction  at  this  point. 
Opportunity  is  thus  offered  for  more  satisfactory  percussion.  Care 
should  be  observed,  however,  to  avoid  turning  the  face  or  inclining 
the  head  sharphj  to  either  side,  as  this  gives  rise  to  overstretching  of  the 
muscles  and  consequent  interference  with  percussion  resonance.  It  is 
often  desirable  that  the  patient  should  sit  during  percussion,  and  rest 
the  back  against  a  straight-backed  chair.  In  examining  the  anterior 
axillary  region  the  arm  may  be  drawn  slightly  backward,  and  in 
percussing  the  posterior  lateral  region  the  arms  may  be  held  a  little 
to  the  front.  When  the  back  is  examined,  the  patient  should  fold  the 
arms,  placing  each  hand  upon  the  opposite  shoulder,  with  the  elbows 
held  as  near  together  as  possible  in  order  to  spread  the  scapulce.  This 
is  particularly  important  in  emaciated  people.  The  patient  is  then 
requested  to  lean  slightly  forward,  rounding  the  shoulders  and  upper 
part  of  the  back  like  a  bow.  If  the  patient  is  examined  in  bed,  attention 
should  be  paid  to  the  maintenance  of  a  symmetric  position  of 
the  shoulders  and  hips. 

Rules  for  the  Physician. — These  refer  to  the  avoidance  of  percus- 
sion instruments,  to  the  position  of  tlie  pleximeter  finger,  the  manner 
in  which  the  lilow  is  dealt  by  the  hammer  finger,  and  the  position  of  the 
examiner  himself. 

Avoidance  of  Percussion  Instruments. — It  is  almost  unnecessary  to 
state  that  the  student  and  practitioner  should  dispense  entirely  with 
all  mechanical  devices  for  the  purposes  of  percussion.  None  of  the 
instruments  of  varied  form  and  character  has  been  found  equal  to  the 
fingers  of  the  examiner.  It  is  much  easier  to  avoid  beginning  the 
employment  of  pleximeters  and  hammers,  than  it  is  to  be  compelled  to 
chspense  with  their  use  subsequently.  Those  who  are  skilled  in  percus- 
sion with  the  fingers  rarely,  if  ever,  need  i-esort  to  mechanical  appliances. 
On  the  other  hand,  those  who  are  accustomed  to  these  instruments  are 
sadly  handicapped  when  obliged  to  percuss  with  their  fingers.  The 
only  possible  advantage  of  pleximeter  and  hammer  in  any  case  is  to 
increase  intensity,  but  the  actual  need  for  this  seldom  exists.  In  many 
instances  their  use  is  contraindicated  because  of  inability  to  apply  the 
instruments  to  small  localized  areas.  Thus,  in  emaciated  inchviduals, 
with  prominent  ribs  and  sunken  intercostal  spaces,  the  pleximeter 
cannot  be  perfectly  adapted  to  the  surface  of  the  chest.  It  is  also 
impossible,  by  the  use  of  these  devices,  to  distinguish  finer  differences 
in  sound  when  percussing;  from  the  ribs  to  the  intercostal  spaces.  In 
children  their  use  often  serves  only  to  frighten  the  child  and  to  render 
the  examination  more  difficult. 

Percussion  with  the  fingers,  however,  is  not  attended  with  any  of 
the  disadvantages  of  pleximeter  and  hammer,  and  in  many  cases  a^rds 


180  PHYSICAL    SIGNS 

a  distinct  aid  to  the  examiner.  The  fingers  are  not  lost,  broken,  or 
forgotten,  and  can  be  applied  to  any  portion  of  the  chest,  and  rarely 
frighten  even  the  most  timid  child.  An  opportunity  is  afforded  to 
appreciate  the  resistance  of  the  part  percussed,  which,  of  course,  is 
impossible  with  any  other  form  of  pleximeter. 

The  Position  of  the  Pleximeter  Finger. — Especial  care  should  be  taken, 
when  comparing  the  two  sides  of  the  chest,  to  percuss  in  symmetric 
regions.  Thus  the  pleximeter  finger  should  not  rest  upon  one  side  over 
a  rib  and  upon  the  other  in  an  interspace;  if  so,  a  difference  in  the 
resonance  will   at  once  be   recognized. 

The  percussion  should  be  made  upon  the  middle  finger  of  the  left 
hand,  which  should  be  firmli/  placed  against  the  chest-wall.  If  due 
attention  is  not  paid  to  this  important  feature,  the  resonance  will  be 
diminished  appreciably  in  intensity,  and  in  many  cases  will  partake  of 
a  peculiar  quality,  to  be  later  described  as  the  "  cracked-pot  resonance." 
A  slight  lifting  of  any  portion  of  the  finger  may  be  sufficient  to  produce 
this  characteristic  sound,  therefore  the  pleximeter  finger  throughout 
its  course  should  be  firmly  pressed  against  the  thorax.  The  other 
fingers  of  the  hand  should  lie  slightly  raised  from  the  surface  of  the 
chest,  in  order  to  avoid  interference  with  the  sound  vibrations. 

Nearly  all  authorities  have  directed  that  the  particular  part  of  the 
pleximeter  finger  upon  which  the  blow  should  be  dealt  is  the  distal 
phalanx  just  back  of  the  nail.  This  I  have  found  to  be  decidedly  less 
desirable  than  the  second  phalanx,  for  several  reasons.  The  bone  is 
much  thicker  and  broader  in  the  second  phalanx,  and  affords  a  better 
medium  for  transmitting  the  vibrations.  Other  things  being  equal, 
those  physicians  make  the  best  examiners  who  have  large  fingers  with 
thick  bones.  The  greater  amount  of  soft  tissue  on  the  dorsal  aspect 
of  the  last  phalanx  affords  a  cushion  for  the  reception  of  the  blow, 
thereby  diminishing  materially  the  intensity  of  the  resonance.  The 
distal  phalanx  just  behind  the  nail,  which  is  invariably  recommended, 
is  more  sensitive  to  repeated  percussion  blows  than  the  dorsal  aspect 
of  the  second  phalanx.  My  attention  was  first  called  to  the  disadvantage 
of  the  distal  phalanx,  because  of  the  inflammation  resulting  from  con- 
stant percussion  upon  this  part,  and  recourse  was  had  to  the  second 
phalanx,  which  was  subsequently  found  to  possess  the  advantages 
previously  described. 

The  pleximeter  finger  should  be  applied  with  equal  and  uniform  force 
when  comparing  the  two  sides  of  the  chest.  Unless  this  precaution  is 
observed,  striking  differences  in  resonance  will  often  faO  of  recognition. 
In  examining  at  the  apices,  particularly  with  the  patient  standing, 
it  is  sometimes  difficult  to  adapt  the  pleximeter  finger  to  the  fossae 
above  the  clavicles  in  ca.se  of  emaciation  or  marked  apical  retraction. 
In  such  cases  the  pleximeter  finger  of  the  left  hand  sliould  be 
applied  to  the  left  apex,  with  the  examiner  in  front.  In  this  posi- 
tion there  is  usually  no  difficulty  in  adapting  the  pleximeter  finger 
to  the  left  side,  while  considerable  trouble  is  experienced  in  applying 
the  finger  to  the  right  apex  of  the  patient.  Under  these  circum- 
stances, when  percussing  the  right  apex,  it  has  been  my  custom  to 
stand  behind  and  to  the  right  of  the  patient.  Percussion  should 
proceed  along  perfectly  straight  lines,  as.  if  practised  at  random 
over  the  thorax,  it  avails  nothing.  In  searching  for  the  percussion 
boundaries  of  certain  organs  it  is  necessary  to  proceed  toward  the 


PERCUSSION 


181 


known  anatomic  border  in  a  line  at  right  angles  with  it.  It  is  also  of 
advantage  in  some  cases  to  keep  the  pleximeter  finger  parallel  to  the 
border  which  it  is  desirea  to  outline. 

The  Manner  in  lohich  the  Blow  is  Dealt. — Comparativelj^  little  atten- 
tion is  paid  by  the  average  practitioner  to  this  feature  of  percussion,  and 
it  is  largely  for  this  reason  that  incorrect  results  are  so  often  obtained. 
The  principle  to  be  observed  in  dealing  the  blow  is  to  deliver  it  quickly, 
the  fingers  instantly  rebounding  like  the  hammer  upon  the  pianoforte 
when  the  keys  are  struck.  The  blow  should  be  repeated  three  or  four 
times  in  quick  succes.sion.  The  slightest  lingering  of  the  hammer 
finger  upon  the  pleximeter  finger  is  sufficient  to  interfere  materially 


with  sound  vibrations,  and  thus  modify  the  resonance.  As  sometimes 
practised,  the  hammer  finger  or  fingers  are  allowed  to  remain  upon  the 
pleximeter  finger  while  the  examiner  listens  to  ascertain  the  character- 
istics of  the  resonance.  It  is  much  better  that  the  middle  finger  of  the 
right  hand  should  serve  as  the  hammer  and  not  permit  the  other  fingers 
to  be  in  contact  with  it.  The  blow  should  be  dealt  with  the  bulbous  tip, 
this  portion  striking  the  pleximeter  finger  always  at  a  right  angle.  It  is 
imperative  that  a  uniform  amount  of  force  be  used  in  delivering  the 
blow,  as  slight  variations  may  result  in  failure  to  bring  out  striking 
differences  of  percussion.  One  of  the  most  important  considorations 
pertaining  to  percussion  relates  to  the  region  from  which  the  hammer 
motion  is  made.     All  writers  who  have  mentioned  this  subject  have 


182  PHYSICAL    SIGNS 

laid  stress  upon  the  fact  that  the  blow  should  be  directed  entirely  from 
the  wrist-joint  and  never  from  the  elbow.  In  so  far  as  relates  to  the 
avoidance  of  any  elbow  movement  this  contention  is,  of  course,  correct. 
It  is  also  true  that  there  must  necessarily  be  some  motion,  no  matter 
how  slight,  from  the  wrist-joint,  but  the  point  is  made  that  for  successful 
percussion  the  best  residts  are  obtained  by  a  gentle  tap  emanating 
very  largely  from  the  carpophalangeal  articulation.  In  Figs.  28  and  29 
will  be  noted  respectively  the  incorrect  and  the  proper  method  of  per- 
cussion. 

The  relative  merits  of  light  and  heavy  percussion  many  times  have 
been  discussed.  There  can  he  no  difference  of  opinion  that,  save  under 
very  exceptional  circumstances,  gentle  percussion  is  far  more  satisfac- 
tory. This  being  so,  there  seems  to  be  little  occasion  for  dealing  the 
blow  from  the  wrist.  This  usually  results  in  lifting  the  finger  and 
hand  as  a  single  piece  of  mechanism  farther  from  the  chest  than  is 
necessary  to  bring  out  clear  vibratory  resonance.  In  most  instances 
a  gentle  tap,  raising  the  hammer  finger  not  over  one  to  two  inches  from 
the  pleximeter  finger,  will  suffice. 

The  PositL07i  of  the  Examiner. — Percussion  should  not  be  attempted 
unless  the  physician  is  perfectly  comfortable,  otherwise  attention  is 
almost  unconsciously  distracted  from  his  work.  When  comparing  the 
two  sides  of  the  chest,  he  should  stand  either  directly  in  front  of  or 
behind  the  patient,  in  oi-der  that  the  sound  may  proceed  to  him  from 
equally  distant  points.  He  should  not  attempt  to  percuss  while  bencUng 
over  the  patient,  as  the  resulting  rush  of  blood  to  tlie  head  interferes 
to  some  extent  with  the  sense  of  hearing.  He  should  endeavor,  as  far 
as  possible,  to  maintain  the  same  relative  position  with  reference  to  the 
patient  when  percussing  various  parts  of  the  chest.  If  the  patient  is 
standing,  the  examiner  may  stand  also,  care  being  taken,  however, 
to  lower  his  own  body  when  examining  the  bases,  particularly  if  the 
patient  is  short.  If  very  tall,  however,  the  patient  should  sit  while  the 
physician  examines  the  apices  and  upper  portions  of  the  chest.  Often 
he  may  be  alile  to  examine  the  lower  portions  of  the  thorax  with  ease 
if  the  patient  is  standing.  If  the  person  examined  be  very  short,  the 
physician  should  so  lower  the  body  that  his  hands  may  be  applied  with 
ease  to  the  part  examined. 

PERCUSSION  OF  THE  NORMAL  CHEST 

There  is  no  fixed  or  arl)itrary  type  of  percussion  resonance  for  the 
normal  chest.  Each  person  necessarily  has  to  furnish  his  own  standard, 
and  it  is  only  by  a  comparison  of  corresponding  parts  of  the  chest  that 
deviations  from  the  normal  can  be  ascertained. 

Regional  differences  are  noted  in  intensity,  pitch,  and  quality. 

The  supraclavicular  region  exhibits  less  intensity  of  resonance 
than  many  other  parts  of  the  che-st,  as  there  is  less  volume  of  lung 
beneath  the  part  percussed.  A  diminution  of  vesicular  qualit}'  is  often 
pronounced  near  the  inner  or  sternal  aspect  of  the  lung,  on  account  of 
proximity  to  the  trachea,  which  contains  a  relatively  large  volume  of  air. 
As  the  vesicular  quality  diminishes  and  the  tympanitic  element  becomes 
more  defined,  the  pitch  correspondingly  rises.  The  characteristics  of 
apex  resonance  are  lessened  intensity,  slight  admixture  of  the  tympanitic 
with  the  vesicular  quality,  and  a  somewhat  higher  pitch. 


PERCUSSION  183 

Similar  changes  are  recognized  upon  percussion  of  the  clavicle  itself. 
The  intensity  is  much  weaker  at  its  outer  or  acromial  end,  while  the 
quality  is  relatively  more  tympanitic  and  the  pitch  higher  at  its  sternal 
end. 

In  the  infraclavicular  region,  extending  from  the  clavicle  to  the 
third  rib,  the  intensity  is  usually  greater  than  in  any  other  part  of  the 
chest,  the  quality  distinctly  vesicular,  and  the  pitch  low.  It  is  possible 
in  some  instances  to  recognize,  however,  a  very  slight  tympanitic  ele- 
ment, with  a  little  elevation  of  the  pitch,  in  the  upper  sternal  region 
from  nearness  to  the  primary  bronchi.  The  characteristics  of  normal 
resonance  are  identical  upon  the  two  sides  of  the  chest  in  this  region, 
as  contrasted  with  the  striking  differences  tlisplayed  below  the  third 
ribs.  The  pre.sence  of  the  underlying  right  auricle  to  the  right  of  the 
sternum  does  not  give  rise  to  any  differences  in  percussion  resonance 
because  of  the  overlapping  lung. 

The  right  and  left  mammary  regions  must  be  considered  separately 
on  account  of  essential  differences  between  the  two  sides.  Upon  the 
right,  the  resonance  is  diminished  in  intensity  on  account  of  the  thicker 
pectoral  muscles  in  the  male  and  the  presence  of  the  mammary  gland 
in  the  female.  The  quality  is  purely  vesicular,  and  the  pitch  low. 
The  intensity  is  further  lessened  from  the  level  of  the  fifth  rib  to  the 
base  of  the  lung,  by  reason  of  the  untlerlying  liver.  This  organ  rises 
to  the  fourth  interspace,  and  in  the  mammary  line  is  covered  by  lung 
to  the  sixth  ril).  The  diminished  resonance,  however,  does  not  cor- 
respond with  its  upper  border,  the  area  of  hepatic  dulness  not  extending 
higher  than  the  fifth  rib  in  the  iiuiinmary  line.  This  is  explained  by 
the  fact  that  the  volume  iif  lung  ('(n-ering  the  liver  from  the  fourth  to 
the  fifth  ribs  is  sufficient  to  conceal  effectually  the  percussion  evidences 
of  the  deep-lying  non-aerated  organ. 

In  the  left  mammary  region  the  resonance  is  modified  by  the  presence 
of  the  heart.  In  this  locality  a  portion  of  the  heart  lies  directly  beneath 
the  chest-wall.  The  apex  is  concealed  by  a  thin,  tongue-like  projection 
of  lung  of  insufficient  volume  to  permit  vesicular  resonance.  The 
upper  portion  of  the  heart  upon  the  left  sifle  is  covered  with  a  layer  of 
lung,  gi\iim-  lisc  ti>  ]iercussion  resonance.  Aldiig  the  thin  edge  of  the 
overhi])piii,u  luiiu  the  resonance  presents  diftciciH'cs  IVom  the  normal 
in  pitch,  (lualit)-,  and  intensity,  by  virtue  of  wiiirli  lieviations  an  area 
of  cardial'  dulness  is  recognized.  Over  the  portion  of  heart  in  immediate 
contact  with  the  chest-wall  there  is  entire  absence  of  resonance,  this 
region  being  known  as  the  area  of  cardiac  flatness.  The  boundaries  of 
the  areas  of  cardiac  dulness  and  flatness  will  be  given  presently. 

The  resonance  elicited  upon  percussion  over  the  very  upper  portion 
of  the  sternum  is  slightly  tympanitic  in  quality,  owing  to  the  proximity 
of  the  trachea. 

Much  confusion  exists  in  the  minds  of  students  and  many  practi- 
tioners as  to  the  normal  resonance  over  the  sternum,  especially  from 
the  second  to  the  sixth  ribs.  This  is  one  of  the  most  important  regions 
of  the  whole  chest,  and  should  always  be  the  first  locality  explored 
upon  percussion. 

Underneath  the  sternum,  between  the  second  and  fourth  ribs,  the 
anterior  borders  of  the  pleura  of  the  right  and  left  sides  lie  immediately 
adjacent  to  each  other.  While  the  right  pleura  descends  almost  ver- 
tically to  the  attachment  of  the  sixth  rib,  the  left  leaves  the  sternum 


184  PHYSICAL    SIGNS 

at  the  lower  edge  of  the  fourth  rib  and  travels  obliquely  outward  and 
downward  across  the  chest.  The  anterior  border  of  the  left  lung  also 
recedes  outwardly  from  the  sternum  opposite  the  fourth  rib,  and 
descends  obliquely  outward  and  downward.  The  anterior  border 
of  the  left  lung  also  recedes  outwardly  from  the  sternum  opposite 
the  fourth  rib,  and  descends  abruptly  to  a  point  near  the  anatomic 
apex  of  the  heart,  where  it  sweeps  forward  and  downward  to  cover 
the  apex,  i.  e.,  the  so-called  lingula  pulmonalis.  A  portion  of  heart 
denudetl  of  lung  and  pleura  lies  in  immediate  apposition  to  the  inner 
aspect  of  the  sternum,  between  the  fourth  and  sixth  ribs.  On  the 
right  side  it  is  covered  by  the  corresponding  lung.  The  lower  portion 
of  the  sternum  overlaps  the  left  lobe  of  the  liver,  and  in  some  instances 
a  portion  of  the  stomach.  In  view  of  these  anatomic  relations  it 
might  be  supposed  that  the  resonance  from  the  second  to  the  fourth 
rib  should  be  entirely  different  in  character  from  that  found  over  the 
lower  portion  of  the  sternum,  and  that  a  similar  variation  should  exist 
upon  percussion  to  the  right  and  left  of  the  mecUan  line  from  the  third 
to  the  sixth  rib.  Imaginary  differences  in  permission  resonance  over 
the  sternum  have  been  described  by  different  writers,  but,  as  a  matter 
of  fact,  there  is  only  a  very  slight  change  in  resonance  between  the 
second  to  the  fourth  rib  and  the  fourth  to  the  sixth.  Generally 
speaking,  there  is  absolutely  no  difference  between  the  resonance  to 
the  right  and  left  of  the  median  line. 

The  sternum  is  an  excellent  conductor  of  sound,  and  transmits 
almost  equally  throughout  its  entire  surface,  as  low  as  the  sixth  rib, 
the  resonance  derived  from  the  underlying  lungs.  For  practical  pur- 
poses the  resonance  over  the  sternum  should  be  regarded  as  uniform  from 
the  .second  to  the  sixth  rib.  Dulness  from  the  fourth  to  the  sixth  rib 
must  be  construed  as  evidence  of  such  underlying  pathologic  con- 
ditions as  pericardial  effusion,  displacement,  hypertrophy  or  dilatation 
of  the  heart,  just  as  dulness  in  the  upper  portion  is  suggestive  of 
aneurysm,  a  possible  distention  of  veins  from  valvular  chsease,  and 
other  causes. 

An  area  in  the  left  anterior  lateral  region,  along  the  lower  margin 
of  the  ribs,  is  known  as  Traube's  semilunar  space.  This  is  bounded 
above  by  the  lower  border  of  the  lungs,  below  by  the  colon,  on  the 
left  by  the  spleen,  and  on  the  right  by  the  left  lobe  of  the  liver.  Per- 
cussion in  this  region  may  show  a  tympanitic  quality,  with  corresponding 
elevation  of  pitch,  thought  to  be  transmitted  from  a  more  or  less  dis- 
tended stomach  or  colon. 

In  the  lateral  regions  of  the  chest  the  percussion  resonance  is  usually 
intense — more  so  than  in  any  other  portion  save  the  infraclavicular. 
The  quality  is  vesicular,  and  the  pitch  relatively  low.  In  the  back  the 
percussion  changes  at  the  apex  are  not  especially  different  from  those 
in  front,  the  variations  in  pitch  and  quality  being  recognized  more 
readily  near  the  spine. 

In  the  interscapular  spaces  the  intensity  is  somewhat  diminished, 
on  account  of  the  thickness  of  the  deep  muscles  of  the  back;  the  pitch 
is  .slightly  raised,  and  the  quality  less  distinctly  vesicular  by  reason  of 
the  closeness  of  the  trachea  and  large  bronchi.  Percussion  resonance 
over  the  scapulse  is  relatively  dull  because  of  the  thickness  of  the 
wing-like  expanse  of  bone  and  soft  parts.  In  the  infrascapular  region, 
on   account   of  the  thickness  of  the  soft    parts,  there   is   recognized  a 


PERCUSSION  185 

diminution  of  intensity  sometimes  necessitating  the  use  of  iieavy  per- 
cussion. 

In  minutely  comparing  corresponding  portions  of  the  chest  it  should 
be  borne  in  mind  that  at  the  apices,  front  and  back,  and  in  the  iippir  iiilrr- 
scapular  regions,  there  exists  a  normal  disparitij  betiveen  the  tiro  sides, 
the  right  being  slightly  higher  in  pitch,  /f.s.s  vesicular  in  quality,  ami  inlh 
diminished  intensity.  i 

Percussion  Boundaries. — In  describing  the  percussion  outlines 
of  the  lung  it  must  be  understood  that  there  is  not  always  an  exact 
correspondence  between  the  anatomic  borders  and  the  resonant  boun- 
daries. The  upper  limit  of  percussion  resonance  is  about  an  inch  and 
a  half  above  the  level  of  the  clavicle,  although  some  little  variation  may 
exist  in  different  individuals.  The  practical  consideration  as  to  the 
height  of  the  lung  in  any  case  relates  chiefly  to  the  amount  of  unilateral 
contraction,  .suggesting  an  existing  or  a  preexisting  tuberculous  process. 
The  lower  border  of  the  lung  upon  the  right  side  in  the  parasternal  line 
is  at  the  fifth  rilj;  in  the  mammary  line,  at  the  sixth,  and  in  the  axillary, 
at  the  seventh.  The  inferior  border  of  the  lung  behind  is  at  the  level 
of  the  eleventh  rib  at  the  vertebral  column.  In  these  localities  pulmo- 
nary resonance  ceases,  the  liver  flatness  usually  affording  a  sharp  line 
of  percussion  demarcation  between  the  two  organs.  As  previously 
stated,  however,  the  line  of  hepatic  dulness  begins  one  rib  higher  than 
the  upper  border  of  hepatic  flatness.  In  this  area  the  volume  of  lung 
is  not  large  enough  to  produce  the  ordinary  type  of  normal  vesicular 
resonance. 

The  change  in  the  lower  border  of  resonance  upon  inspiration  and 
expiration  is  called  the  active  vioiiUHy  of  the  lungs. 

Upon  expiration  the  lung  tloes  not  meet  the  attachment  of  the 
pleura.  Upon  full  inspiration,  howe^'er,  it  descends  to  this  point, 
completely  filling  the  space  formerly  occupied  by  the  diaphragm  and 
costal  borders.  With  returning  oxjiii'Mtion  tlio  diaphragm  ri.^es  and 
the  sides  of  the  chest-wall  retract,  (iblitnatiui;  the  sd-callcd  •■  comple- 
mental  space"  of  Gerhardt.  Oppoii  unity  is  thus  art'i>i<l('d  fur  striking 
differences  in  the  lower  percussion  Ixjundaries  of  the  lung. 

A  difference  in  the  inferior  border  is  also  noticed  upon  change 
in  the  position  of  the  individual.  This  is  called  the  passive  mobility 
of  the  lungs.  It  has  Ijeen  found  that  the  lower  border  is  somewhat 
lower  with  the  patient  reclining  than  when  standing,  and  in  like  manner 
the  right  lung  depressed  when  he  is  upon  the  left  side.  While  not  of 
very  especial  importance,  these  facts  should  be  boi-ne  in  mind  when  an 
examination  is  made  with  the  patient  in  these  positions.  It  should  be 
remembered  also  that  whenever  the  volume  of  the  lung  has  been  notably 
increased  from  emphysema,  the  inferior  borders  will  be  appreciably 
lowered. 

The  Area  of  Cardiac  Dulness. — The  upper  border  of  this  region  is 
the  lower  edge  of  the  third  rib,  from  its  attachment  to  the  sternum 
outward  nearly  to  the  mammary  line,  where  it  descends  almost  vertically 
to  form  the  left  border,  passing  through  or  just  inside  the  nipple.  The 
right  boundary  is  the  left  edge  of  the  sternum.  As  to  its  boundary, 
however,  authorities  differ  within  wide  limits,  some  placing  the  right 
border  of  percussion  dulness  at  about  one  centimeter  to  the  right  of 
the  left  edge  of  the  sternum,  and  others  even  at  its  right  margin.  While 
it  is  admitted  that  in  some  cases,  particularly  in  children,  very  careful 


186  PHYSICAL    SIGNS 

percussion  will  elicit  appreciable  dulness  beyond  the  left  margin  of  the 
sternum,  it  is,  nevertheless,  true  that  for  practical  purposes  in  adult 
life,  the  right  boundary  of  cardiac  dulness  may  be  assumed  to  be  the 
left  edge  of  the  sternum.  The  lower  boundary  cannot  be  outlined  on 
account  of  the  iinmediate  proximity  of  the  left  lobe  of  the  liver. 


30. — Areas  of  normal  cardiac  dulness  and  flatness  in  adults. 


The  area  of  cardiac  flatness  has  for  its  right  border  the  left  edge  of 
the  sternum,  precisely  as  the  area  of  cardiac  dulness.  Its  upper  border 
is  along  the  fourth  rib,  from  its  attachment  to  the  sternum  outwardly 
to  a  point  about  one  inch  inside  the  mammary  line.  From  this  it 
descends  vertically  and  ends  in  the  left  lobe  of  the  liver,  as  does  the  cor- 
responding boundary  of  the  area  of  cardiac  dulness.  The  two  areas  are 
of  irregular  quadrangular  shape. 

As  the  small  projection  of  lung  covering  the  apex  of  the  heart  is 
not  of  sufficient  thickness  to  yield  percussion  resonance,  these  areas 
of  cardiac  dulness  and  flatness  offer  a  striking  illustration  of  the 
dissimilarity  between  anatomic  conditions  and  percussion  boundaries. 
Allowance  should  be  made  for  variations  at  different  times  of  life.  In 
children  both  the  areas  of  dulness  and  flatness  ai-e  much  larger  than  in 
adults,  the  flatness  in  some  instances  extending  as  high  as  the  third  rib, 
and  to  the  left,  well  beyond  the  nipple,  antl  sometimes  even  to  the  right 
of  the  sternum.  In  old  age  the  percussion  regions  are  relatively  small 
in  size,  the  upper  border  of  flatness  sometimes  being  as  low  as  the  fifth 
rib.  The  areas  of  flatness  and  dvilness,  like  the  lower  liorder  of  the  lung, 
are  subject  to  considerable  differences  in  size  as  a  result  of  the  active 
mobility  of  the  lungs.  In  the  same  way  marked  emphy.sema  may 
diminish  the  areas  sufficiently  even  to  cause  their  complete  obliteration. 

PERCUSSION  IN  THE  MIDST  OF  ABNORMAL  STATES 

It  must  not  be  suppo.sed  that  percussion  in  itself  is  sufficient  for 
the  accurate  chagnosis  of  diseased  conditions.  It  simply  affords  the 
examiner  more  or  less  exact  information  with  reference  to  the  increase 
or  diminution  of  the  air-content.     The  knowledge  derived  from  per- 


PERCUSSION  187 

cussion  in  association  with  the  history  and  rational  signs,  together  with 
recourse  to  other  methods  of  examination,  is  sufficient  to  establish 
in  most  instances  a  positive  diagnosis. 

The  recognition  of  percussion  signs  relates  to  the  presence  or  absence 
of  resonance,  changes  in  intensity,  changes  in  quality,  and  changes  in 
pitch. 

It  has  been  stated  that  the  standard  of  percussion  resonance  of  one 
person  rarely  corresponds  to  that  of  another,  and  that  the  character 
of  the  resonance  in  some  portions  of  the  chest  varies  materially  from 
that  obtained  in  other  localities.  Thus  a  percussion  resonance  may  be 
recognized  as  normal  for  particular  regions,  while  the  same  resonance 
elicited  in  a  different  portion  of  the  chest  would  be  regarded  as  a  distinct 
deviation  from  the  normal.  In  searching  for  the  physical  evidences  of 
morbid  conditions,  the  regional  differences  of  percussion  should  con- 
stantly be  borne  in  mind. 

It  has  been  stated  that  percussion  resonance  is  analyzed  with  refer- 
ence to  intensity,  pitch,  and  quality,  and  that  the  normal  resonance  of 
the  lungs  in  general  is  variable  in  intensity,  low  in  pitch,  and  purely 
vesicular  in  quality.  Duration  may  hardly  be  regarded  as  of  sufficient 
importance  to  require  more  than  passing;  mention  in  tliis  connection. 

Complete  Absence  of  Percussion  Resonance  or  Flatness. — There 
being  no  resonance,  there  can  lie  no  appreciation  of  intensity,  pitch,  or 
quality.  The  sound  elicited  is  entirely  devoid  of  these  characteristics, 
and  is  precisely  such  as  would  be  obtained  in  tapping  over  a  solid  body, 
as  over  the  thigh  or  the  arm. 

For  the  production  of  total  flatness  certain  pathologic  conditions 
are  necessary.  Such  changes  may  exist  respectively  within  the  pleural 
cavity,  the  lungs,  or  the  bronchial  tubes. 

The  presence  of  liquid  within  the  pleural  cavity,  as  in  pleurisy  with 
effusion,  empyema,  pneumopyothorax,  or  hydrothorax,  may  be  suffi- 
cient to  cause  complete  flatness  upon  percussion,  but  it  does  not  follow 
that  flatness  will  result  in  all  cases.  For  example,  in  children  with 
left-sided  empyema  a  transmitted  stomach  resonance  may  replace  the 
flat  note  incident  to  the  purulent  effusion.  There  may  be  complete 
flatness  in  some  instances  and  only  dulness  or  diminished  resonance 
in  others,  according  to  the  amount  of  liquid.  If  the  size  of  a  pleural 
effusion  is  small,  flatness  in  most  cases  will  be  found  in  the  lower 
portion  of  the  chest,  particularly  in  the  back  and  in  the  lower  axillae. 
In  extreme  cases,  however,  this  is  often  obtained  upon  percussion 
in  the  middle  and  upper  portions.  In  pneumopyothorax,  the  liquid 
being  entirely  in  the  dependent  portion  of  the  chest,  absolute  flatness 
is  found  at  the  bases. 

The  conditions  within  the  lungs  sufficient  to  produce  flatness  are 
those  which  are  accompanied  by  complete  consolidation.  This  may 
occur  as  a  result  of  pneumonia,  pulmonary  tuberculosis,  the  excessive 
compression  of  lung  from  accompanying  pleural  effusion,  collapse  or 
atelectasis  of  the  lung,  gangrene,  pulmonary  infarction  of  large  size,  or 
rarely  new-growths  arising  from  the  pulmonary  tissues. 

Pneumonic  .solidification,  according  to  its  degree,  may  or  may  not 
be  attended  by  entire  flatne.ss.  Tuberculous  consolidation  is  seldom 
so  complete  as  to  produce  absolute  flatness,  although  occasionally  this 
is  found  to  be  the  case.  Compression  of  lung  by  pleural  effusion  is 
rarely  sufficient  to  effect  a  complete  disappearance  of  resonance.    The 


188  PHYSICAL    SIGNS 

same  is  true  of  pulmonary  infarctions,  which  are  often  so  small  in 
area  as  to  escape  tletection  upon  physical  examination.  New-growths 
within  the  chest  having  the  characteristics  of  a  solid  tumor,  if  situated 
superficiallj'  and  of  sufficient  size,  yield  entire  absence  of  resonance 
upon  percussion.  Gangrene  of  the  lung  may  be  so  extensive  as  to 
give  rise  to  flatness.  The  same  is  true  of  abscess  of  the  lung  and  pulmo- 
nary cavities  filled  with  liquid. 

The  part  played  by  the  finer  bronchi  in  the  production  of  flatness 
consists  of  the  exudation  incident  to  pneumonia,  the  extravasation  of 
large  quantities  of  Ijlood  accompanying  pulmonary'  hemorrhages,  and  the 
transudation  of  serum  into  the  finer  tubes  in  cases  of  pulmonary  edema. 
It  is  not  maintained  for  a  moment  that  the  changes  referable  anatomic- 
ally to  the  finer  bronchi  should  be  regarded  as  of  general  importance  in 
the  causation  of  flatness.  These  changes  occur,  however,  incident  to 
other  conditions,  and,  therefore,  are  worthy  of  mention  in  this  connection. 

Changes  in  Intensity. — The  intensity  of  the  percussion  resonance 
may  be  either  increased  or  diminished.  It  is  increased  in  children  and 
in  acute  compensatory  emphysema,  on  account  of  the  increased  tension 
of  the  pulmonary  tissues. 

In  the  latter  instance  the  volume  of  the  lung  is  greater,  the  stretch- 
ing of  the  tissues  of  more  recent  duration,  their  elasticity  as  yet  unim- 
paired, relaxation  not  having  taken  place,  and  increased  resonance 
results,  precisely  as  in  children.  Coincident  with  the  exaggerated  reso- 
nance there  also  are  recognized  slight  changes  in  pitch  and  quality. 
The  pitch  is  somewhat  elevated  and  the  quality  less  vesicular,  or  often 
tympanitic  in  character.  In  view  of  the  fact  that  the  important 
distinctive  changes  of  the  resonance  in  these  conditions  relate  more 
particularly  to  differences  in  pitch  and  quality,  the  increased  intensity 
must  be  regarded  as  of  relatively  minor  importance. 

Diminished  intensity  may  exist  whenever  there  is  a  greater  relative 
amount  of  solid  or  liquid  to  air  in  a  triven  ]inrtinn  of  the  chest.  It  may 
be  occasioned  by  the  same  conditions,  previously  described,  which,  if 
present  to  a  greater  extent,  would  lie  -iilHcicnt  to  produce  flatness. 
Aside  from  liquid  within  the  pleural  i;u\ity,  a  diminished  resonance 
may  l)e  effected  by  pleural  thickening  or  by  the  presence  of  considerable 
exudate  upon  the  pleural  surface.  Pulmonary  changes  respon.sible 
for  dulness  are  pa^-tial  consolidations,  as  in  the  early  stage  of  pneumonia 
or  after  resolution  has  begun,  tuberculous  infiltrations,  and  compres- 
sions from  pleural  effusions,  gangrene,  infarction,  etc.  Moderate  edema 
and  extravasation  of  blood  or  other  secretions  into  the  smaller  bronchial 
tubes  may  produce  areas  of  dulness.  particularly  at  the  bases. 

Diminished  intensity  is  always  associated  with  elevation  of  pitch 
and  weakened  vesicular  quality. 

Changes  in  Quality. — All  resonance  which  is  not  vesicular  must  be 
regarded  as  tympanitic  in  quality.  There  are  several  varieties  of 
non-vesicular  resonance,  conforming  in  general  to  the  tympanitic  type. 
These  may  be  described  as  pure  tympanitic  resonance,  amphoric 
resonance,  and  cracked-pot  resonance. 

Ti/mpanitic  Resonance. — This  may  occur  in  the  presence  of  large 
cavities  containing  air,  pneumothorax,  pneumonic  consolidation  of 
the  upper  lobe,  consolidation  of  the  lateral  portion  of  the  left  lung, 
compres.sion  of  lung  above  the  level  of  a  pleural  effusion,  or  long- 
standing ca.ses  of  asthma  and  chronic  pulmonary  emphysema. 


PERCUSSION  189 

Tympanitic  resonance  is  found  but  infrequently  over  pulmonary 
cavities.  While  some  examiners  by  this  means  assume  to  recognize 
cavities  of  exceedingly  small  size,  experienced  clinicians,  as  a  rule,  do 
not  hesitate  to  disclaim  ability  to  detect  them  by  percussion  signs 
alone.  It  is  believed  by  the  best  observers  that  tympanitic  resonance, 
as  a  result  of  pulmonary  excavation,  can  be  elicited  only  when  the  cavity 
is  located  near  the  surface  of  the  lung,  and  approximately  the  size  of 
a  man's  fist.  This  form  of  resonance  is  found,  however,  amid  a  variety 
of  conditions.  In  view  of  these  facts  it  is  easy  to  appreciate  the  relative 
unimportance  of  this  sign  in  the  diagnosis  of  pulmonary  cavities. 

Tympany  is  often  obtained  in  pneumothorax,  but  on  account  of 
the  anatomic  changes  the  resonance,  in  many  cases,  more  closely 
approaches  the  amphoric  type. 

During  percussion  over  a  pneumonic  consolidation  of  the  upper 
lobe  a  tympanitic  note  is  sometimes  elicited  as  a  result  of  the  trans- 
mission of  vibrations  from  air  contained  in  the  trachea  or  primary 
bronchi.  This  is  described  as  "  William's  tracheal  tone."  When  such 
transmission  does  not  take  place,  tympany  is  obtained  in  some  instances 
over  a  partial  pneumonic  consolidation  by  virtue  of  the  diminished 
tension  of  pulmonary  tissues. 

Tympanitic  resonance  may  be  elicited  upon  percussion  of  a  localized 
area  of  consolidation  in  the  immediate  neighborhood  of  the  stomach, 
the  vibrations  being  conducted  from  the  large  air-containing  organ. 

In  beginning  tuberculous  infiltration  at  the  apex  tympany  is  occa- 
sionally found,  owing  to  the  relaxation  of  the  pulmonary  structures. 

The  same  cause  also  accounts  for  the  tympanitic  quality  obtained 
upon  percus.sion  of  lung  compressed  by  pleural  effusion.  In  vesicular 
emphysema  the  causal  agent  for  the  production  of  tympany  is  the 
relaxation  of  the  pulmonary  tissue,  but  the  resonance  is  usually  an 
admixture  of  the  vesicular  and  the  tympanitic  types.  In  such  cases 
the  predominating  tympanitic  quality  with  accompanying  elevation  of 
pitch  corresponds  to  the  extent  of  the  emphysematous  condition. 

Amphoric  Resonance. — Contrary  to  the  general  teaching,  this  should 
not  be  regarded  as  a  separate  and  distinct  type.  It  is  strictly  a  variety 
of  tympanitic  resonance,  differing  only  to  the  extent  that  there  is 
superadded  a  peculiar  musical  intonation.  It  is  noteworthy  that  the 
similarity  of  the  tympanitic  and  amphoric  quality  is  supplemented 
by  the  fact  that  the  two  varieties  of  resonance  maj'  be  observed  in 
almost  identical  conditions.  The  musical  quality  may  be  imitated  by 
tapping  the  cheek  with  the  mouth  open,  the  jaws  more  or  less  widely 
.separated,  and  the  muscles  of  the  cheek  drawn  as  tensely  as  possible. 
With  the  mouth  open  wide  the  pitch  is  relatively  high,  but  it  becomes 
low  as  the  opening  is  made  smaller.  A  suggestion  of  the  sound  is 
also  obtained  by  gently  tapping  the  outside  of  a  jar,  from  which  the  name 
amphoric  is  derived.  Inasmuch  as  a  jar  has  a  firm,  unyielding  wall 
with  a  smooth  inner  surface,  air  being  admitted  freely  through  an 
opening  of  variable  size,  it  may  be  assumed  that  the  pathologic  change 
within  the  thorax  likely  to  produce  this  form  of  resonance  should 
represent  an  analogous  condition.  It  is  true  that  amphoric  reso- 
nance may  often  be  elicited  over  pulmonary  cavities  containing 
air  and  having  free  communication  with  a  bronchial  tube.  For 
its  production,  however,  it  is  also  necessary  that  the  cavity  should  be 
more  or  less  regular  in  shape,  of  considerable  size,  and  with  smooth, 


190  PHYSICAL    SIGNS 

comparatively  tense  walls.  As  these  physical  conditions  are  seldom 
present  in  pulmonary  excavation,  it  is  of  but  little  value  as  a  cavity 
sign. 

In  open  pneumothorax  with  collapsed  lung  a  large  body  of  air  is 
contained  within  the  pleural  cavity,  which  opens  into  a  bronchial 
tube.  The  surrounding  wall  is  smooth,  firm,  and  fairly  regular  in 
shape,  and  hence  amphoric  resonance  is  easily  recognized.  This  is  not 
always  present,  however,  in  pneumothorax,  and  there  are  other  con- 
ditions in  which  it  may  be  obtained.  Occasionally  it  is  observed  upon 
percussion  over  compressed  lung  in  cases  of  pleural  effusion.  This 
sign  may  be  elicited,  though  not  often,  in  the  early  stages  of  pneumonia, 
before  consolidation  has  become  complete.  The  chief  distinguishing 
characteristic  of  amphoric  resonance  is  simply  a  musical  intonation 
added  to  a  quality  distinctly  tympanitic. 

Cracked-pot  Resonance. — This  form  of  resonance,  like  the  amphoric, 
is  tympanitic  in  character,  and  should  not  be  regarded  as  a  separate 
variety.  Its  tympanitic  quality  is  so  modified  as  to  suggest  the 
sound  obtained  by  tapping  a  jar  which  is  badly  cracked.  It  is  some- 
times described  as  a  chinking  resonance,  on  account  of  a  resemblance 
to  the  chinking  of  coin.  It  may  be  imitated  by  clasping  the  hands 
together  loosely  and  tapping  them  against  the  knee,  thus  forcibly 
expelling  the  air.  Although  cracked-pot  resonance  is  commonly  sup- 
posed to  be  pathognomonic  of  pulmonary  cavities,  such  is  not  always 
the  case.  This  is  occasionally  recognized  upon  percussion  over  pul- 
monary cavities,  but  it  is  present  as  well  in  other  conditions.  It  may 
be  heard,  like  the  amphoric,  upon  percussion  of  compressed  lung 
accompanying  pleural  effusion,  and  sometimes  in  early  stages  of  pneu- 
monia. This  sign  is  often  noted  during  the  percussion  of  young  children, 
particularly  if  the  lungs  are  overdistended  from  crying.  A  cracked-pot 
resonance  is  not  infrequent  in  very  thin-chested  people,  and  is  fairly 
common  whenever  the  pleximeter  finger  throughout  its  entire  length 
is  not  held  firmly  against  the  cliest.  A  small  layer  of  air  between  a 
portion  of  the  finger  and  the  wall  of  the  thorax  often  produces  the 
characteristic  sound. 

Changes  in  Pitch. — Allusion  has  been  made  to  the  changes  of  pitch 
incident  to  tympanitic  resonance,  which  apply  equally  to  the  amphoric 
or  cracked-pot  varieties.  The  distinguishing  characteristics  of  all 
deviations  from  the  normal  vesicular  resonance  relate  not  primarily 
to  the  change  in  pitch,  but  rather  to  differences  of  quality  or  intensity. 
There  ai'e,  however,  changes  of  pitch  independent  of  essential  differences 
of  quality  or  intensity. 

It  is  found,  with  the  mouth  of  the  patient  open  during  percussion 
over  relaxed  pulmonary  tissue,  that  the  pitch  is  more  elevated  than 
when  it  is  closed.  This  is  readily  appreciated  by  listening  with  the 
stethoscope  while  percussing,  the  bell  of  the  instrument  being  held  by 
the  patient  close  to  the  open  mouth.  This  change  of  pitch  in  the 
upper  portion  of  the  chest  is  found  to  apply  to  a  tympanitic  resonance 
arising  from  any  cause. 

Wintrich's  change  of  pitch,  as  described  above,  has  been  supposed 
to  obtain  merely  in  the  cafse  of  tympanitic  resonance  resulting  from  a 
pulmonary  cavity,  but  the  same  phenomenon  may  be  elicited  upon 
careful  examination,  whatever  may  be  the  immediate  cause  of  the  tym- 
pany.     By  "  Wintrich's   interrupted  change  of  pitch  "  is   meant  the 


AUSCULTATION  191 

detection  of  an  elevated  pitch  with  the  stethoscope  before  the  open 
mouth  when  the  patient  is  in  a  certain  position,  and  failure  to  recog- 
nize the  same  deviation  when  another  position  is  assumed.  This  sign 
must  be  regarded  as  strongly  suggesting  the  existence  of  a  cavity 
partially  filled  with  liquid,  the  level  of  which  varies  according  to  the 
position  of  the  patient. 

Gerhardt's  change  of  pitch  relates  to  a  difference  obtained  accord- 
ing to  the  position  of  the  patient,  without  any  reference  to  the 
opening  or  closing  of  the  mouth.  The  physical  condition  necessary 
for  its  production  is  the  presence  of  a  cavity,  oval  in  shape,  partially 
filled  with  liquid.  If  the  longitudinal  diameter  of  the  cavity  corresponds 
with  the  vertical  axis  of  the  body,  it  will  be  seen  that  the  column  of  air 
above  the  level  of  the  liquid  is  much  higher  with  the  patient  in  the  erect 
position  than  is  the  case  when  reclining.  A  distinct  variation  in  pitch 
over  a  small  circumscribed  area,  according  to  the  position  of  the  patient, 
presents  strong  percussion  evidence  of  a  pulmonaiy  cavity. 

Taken  as  a  whole,  however,  the  percussion  signs  of  pulmonary  cavi- 
ties are  exceedingly  unreliable.  As  a  matter  of  fact,  they  are  recognized 
with  ease  upon  auscultation  when  no  percussion  evidence  of  their  exis- 
tence can  be  detected.  The  several  forms  of  resonance,  exhibiting 
variations  in  pitch  and  quality,  occasionally  obtained  upon  percussion 
over  cavities,  constitute  considerations  of  much  interest,  but  rarely  of 
definite  pathognomonic  value  to  the  examiner. 


CHAPTER   XXXII 
AUSCULTATION 


Auscultation  as  applied  to  the  lungs  refers  to  the  act  of  listening 
to  the  sounds  producecl  by  respiration,  the  voice,  and  artificial  cough. 
There  is  no  method  of  physical  examination  so  confusing  to  students, 
if  not  to  practitioners,  as  auscultation.  An  explanation  is  found  not 
so  much  in  the  lack  of  facilities  to  acquire  practical  experience,  as  in 
failure  to  utilize  the  opportunities  which  are  presented.  This  in  turn 
is  supplemented  not  infrequently  by  inadequate  preliminary  instruc- 
tion relative  to  auscultation.  The  methods  of  teaching  this  branch  in 
medical  schools  vary  within  wide  limits,  and  a  decided  lack  of  uni- 
formity is  also  exhibited  in  the  manner  in  which  the  subject  is  treated 
in  various  text-books.  Several  entertain  radically  opposing  views  with 
reference  to  matters  of  classification  or  nomenclature,  the  analytic 
characteristics  of  some  of  the  sounds  produced,  their  interpretation, 
and  association  with  other  signs.  It  is  not  strange  that  students  expe- 
rience difficulty  in  securing  an  intelligent  understanding  of  the  subject, 
and  that  practitioners  report  a  diversity  of  auscultatory  findings.  It 
is  not  the  bedside  teaching  alone  nor  the  clinical  facilities  offered  in 
dispensaries,  which,  for  this  particular  branch,  should  be  regarded  as  of 
prime  importance.  The  observation  and  study  of  abnormal  conditions, 
rendered  possible  by  excellent  clinical  advantages,  are  not  so  essential 
as  preliminary  instructions  regarding  normal  conditions.     It  is  com- 


192  PHYSICAL    SIGNS 

paratively  easy  for  the  student  to  recognize  deviations  from  the 
normal  when  he  has  become  thoroughly  familiar  with  the  sounds  of 
respiration  in  health.  Before  beginning  the  examination  of  normal 
chests,  however,  he  should  be  taught  systematically  the  principles 
and  arbitrary  facts  of  auscultation.  It  is  desirable  that  uniformity 
of  method  should  be  observed  in  the  manner  of  imparting  instruction, 
but  it  seems  unavoidable  that  a  diversity  of  teaching  should  arise  as  a 
result  of  the  differing  experience  and  opportunities  of  observers.  In 
the  description  that  is  to  follow  no  attempt  will  be  made  to  conform  to 
the  expressed  opinions  of  others  further  than  has  been  established  by 
personal  experience.  No  teacher  can  assume  the  responsibility  of 
describing  what  is  not  to  him  the  actual  result  of  his  observation.  An 
appreciative  reference  is  here  made  to  the  most  excellent  work  of  Austin 
Flint,  published  more  than  twenty  years  ago,  from  which  the  author 
derived  his  early  instruction  concerning  the  principles  of  auscultation, 
and  which,  to  some  extent,  has  served  as  a  guide  for  clinical  observation 
and  teaching.  The  only  aim  of  these  pages  will  be  toward  simplicity 
and  clearness. 

MANNER  OF  AUSCULTATION 

Auscultation  may  be  practised  either  with  or  without  the  aid  of  an 
instrument  called  the  stethoscope.  When  this  is  not  used,  the  exam- 
iner places  his  ear  directly  against  the  chest  or  some  intervening 
fabric,  as  a  towel  or  undergarment.  Auscultation  thus  performed  is 
called  the  direct  or  immediate  method,  and  is  employed  more  by  older 
practitioners  than  by  those  who  have  graduated  from  medicine  during 
the  past  quarter  of  a  century.  Some  diagnosticians  of  experience  con- 
tinue to  advocate  the  practice  of  direct  auscultation,  but  the  great 
majority  of  clinicians  have  discarded  it  save  under  exceptional  con-' 
ditions.  Physicians  unaccustomed  to  the  continued  use  of  the  stetho- 
scope are  more  certain  of  their  auscultatory  findings  when  employing 
the  direct  method,  while  students  who  are  not  experienced  in  direct 
auscultation  often  find  considerable  difficulty  in  appreciating  phj'sical 
signs  which  are  perfectly  easy  of  recognition  with  the  stethoscope. 
The  direct  method  does  not  possess  any  advantage  of  moment  over 
the  indirect.  The  claim  sometimes  made  that  it  is  of  considerable 
value  in  enabling  the  examiner  to  recognize  deep-seated  conditions 
within  the  lungs  is  much  less  valid  than  formerly,  on  account  of  the 
comparatively  recent  introduction  of  a  stethoscope  peculiarly  applic- 
able for  this  purpose.  Manifest  disadvantages,  however,  attach  to  the 
direct  method. 

The  first  objection  to  its  use  is  the  fact  that  one  cannot  hear  as 
plainly  as  with  the  stethoscope,  provided  both  methods  are  practised 
to  an  equal  extent. 

In  direct  auscultation  it  is  much  more  difficult  to  exclude  extraneous 
sounds.  Although  the  disturbing  effect  of  noises  in  the  room  may  be 
minimized  by  placing  a  finger  in  the  other  ear.  a  buzzing  or  humming 
is  produced,  obscuring  in  a  measure  the  auscultatory  sounds. 

The  employment  of  the  direct  method  of  auscultation  predisposes 
to  lax  and  superficial  examinations.  The  sounds  are  conveyed  to  a 
degree  through  the  clothing,  and  physicians  in  the  midst  of  a  busy 
practice  fall  into  the  unfortunate  habit  of  conducting  an  examination 
without  the  denudation  of  the  chest.     Examinations  thus  made  are 


AUSCULTATION  193 

necessarily  imperfect  and  afford  ample  opportunity  for  inaccurate  con- 
clusions. 

Parts  of  the  chest,  notably  the  apical  regions,  on  account  of  their 
anatomic  configuration,  are  not  susceptible  of  a  thorough  examination 
by  the  application  of  the  ear. 

It  is  impossible  with  this  method  to  circumscribe  definitely  the  area 
from  which  sounds  are  to  be  derived. 

If  the  examination  be  conducted  in  a  thorough  manner  with  the 
chest  bare  of  clothing,  the  direct  method  should  be  discountenanced 
for  women  on  the  score  of  propriety. 

Among  the  ignorant  and  imclean  the  application  of  the  ear  to  the 
skin  is  not  agreeable  to  the  examiner,  and  is  often  unsafe,  through  the 
tlanger  of  possible  contagion  from  parasites. 

These  disadvantages  of  direct  auscultation  without  any  compensa- 
tory benefits  would  seem  to  constitute  sufficient  objection  to  its  employ- 
ment, save  when  the  stethoscope  is  not  available. 

The  stethoscopic  method  is  found  to  remove  all  the  foregoing  objec- 
tions. The  respiratory  sounds  are  clearer  and  more  intense,  greater 
concentration  is  afforded  by  the  exclusion  of  noises  from  the  street  or 
within  the  room,  and  regions  incapable  of  examination  with  the  ear  are 
readily  accessible  by  means  of  the  instrument.  In  addition,  sounds 
are  obtained  over  a  definitely  circumscribed  area,  superficial  examina- 
tions are  less  likely  to  result,  and  embarrassment  on  the  part  of  the 
patient  or  examiner  is.  to  a  great  extent,  avoided.  Some  objections 
to  the  use  of  the  stethoscope  have  been  suggested,  but  all  are  of  com- 
paratively minor  importance  and  scarcely  worthy  of  mention.  This 
will  be  discussed  under  the  rules  for  the  performance  of  auscultation. 

THE   STETHOSCOPE 

Many  stethoscopes  of  varying  degrees  of  merit  have  been  intro- 
duced. Some  are  exceedingly  good  for  general  employment;  others 
possess  a  peculiar  adaptability  for  certain  purposes,  and  a  few  are 
very  inferior  for  any  use  whatever.  There  is  so  radical  a  difference 
in  details  of  construction  among  numerous  stethoscopes  that  it  may 
be  assumed  if  one  affords  an  excellent  transmission  of  sound,  many 
of  the  others  must  be  less  desirable.  If  the  sound  is  transmitted  to 
the  ear  chiefly  through  the  current  of  air  within  tlic  tube,  rather  than 
through  the  solid  parts  of  the  instrument,  it  is  hard  to  understand  why 
there  should  exist  such  a  lack  of  uniformity  in  the  diameter  of  the  air 
column.  In  some  of  the  instruments  the  solid  and  flexible  tubes  are  of 
minute  size,  while  in  others  they  are  of  much  larger  diameter. 

As  to  the  solid  parts  of  the  instrument,  there  is  found  a  decided 
difference  in  the  shape  and  size  of  the  ear-pieces,  in  the  degree  and 
direction  of  the  curve  proximal  to  the  binaural  extremity,  in  the  material 
composing  the  solid  tubes  irrespective  of  size,  in  the  joints,  and  in  the 
character  and  construction  of  the  spring,  in  the  thickness  and  length 
of  the  rubber  tubing,  and  in  the  dimensions,  form,  and  composition 
of  the  bell  of  the  in.strument.  It  is  evident  that  some  stethoscopes 
have  been  designed  with  a  view  to  the  conduction  of  respiratory  sounds 
through  the  solid  parts  of  the  instrument  rather  than  through  the  con- 
tained column  of  air.  A  few  are  found  to  increase  the  intensity  of  the 
sounds,  but  at  the  same  time  to  impart  a  peculiarlj^  metallic  quality, 

13 


194 


PHYSICAL    SIGNS 


In  the  majoritj-  of  cases  intensity  does  not  constitute  an  important 
analytic  characteristic  of  auscultatory  sounds,  but  differences  in  the 
quality  and  pitch  are  of  supreme  significance.  Provided  the  sounds  are 
of  sufficient  intensity  to  be  clearly  distinguishable,  there  is  nothing  to  be 


Fig.  31. — Foreshortened  view  of  unjoiiited  Camman  instrument.  Note  large  size  of  ear- 
pieces and  moderate  cur\'e  of  the  tube  immediately  adjacent,  also  the  comparatively  large  size 
of  the  tubes,  hard-rubber  bell,  and  absence  of  metallic  spring. 

gained  by  the  use  of  an  instrument  increasing  intensity  at  the  expense 
of  tlifferences  in  quality. 

Such  a  stethoscope  should  be  employed  as  will  permit  the  conduction 
of  the  sound  as  little  unchanged  as  possible  to  the  ear.  Physicians 
always  obtain  more  satisfactory  results  when  using  an  instrument  to 


Fig.  32.— Jointed 


ethoscope  with  exaggerated  curve  adjacent  to  t 
shaped  bell  and  the  small  projecting  thumb 


which  they  have  been  accustomed.  Certain  styles  are  adapted  to 
some  examiners,  and  especially  contraindicated  for  others.  It  is  as 
necessary  to  select  the  stethoscope  with  a  view  to  its  appropriateness 
for  the  examiner  as  his  shoes,  hat,  or  gloves.  In  choosing  a  stetho- 
scope  attention   must  be  given  to  all  the  details  of  its  construction. 


AUSCULTATION  195 

Brief  reference  will  be  made  to  the  most  important  parts  of  the  instru- 
ment from  the  ear-pieces  to  the  bell. 

Care  should  be  exercised  not  to  permit  the  ear-pieces  to  extend 
too  far  into  the  external  auditory  canal.  If  so,  a  feeling  of  discomfort, 
if  not  of  actual  pain,  is  experienced,  and  the  hearing  becomes  less  acute. 
The  ear-pieces  should  be  of  good  size  that  they  may  not  impinge  too 
tightly  into  the  meatus. 

One  of  the  most  important  considerations  in  selecting  a  stethoscope 
is  the  direction  of  the  curve  adjacent  to  the  ear-pieces.  Figs.  31,  32, 
33,  34,  and  35  illustrate  the  striking  differences  in  this  respect  exhibited 
by  several  stethoscopes  in  extended  use.  In  order  to  obtain  the  best 
results,  the  direction  of  the  curve  should  correspond  to  the  course  of  the 
external  auditory  canal,  otherwise  the  aural  aperture  of  the  stethoscope 


Fig.  33. — Illustrating  still  more  exagpen 
the  size  of  m 

will  be  directed  toward  the  cartilaginous  portion  of  the  canal  and  obstruct, 
to  a  vast  extent,  the  sound  transmission.  It  is  obvious  that  if  any  one  of 
the  foregoing  instruments  is  perfectly  adapted  to  an  individual,  all  the 
others  must  be  quite  inappropriate.  The  direction,  as  well  as  the  extent, 
of  the  curve  may  be  subject  to  enormous  variation.  While  the  student 
can  often  ascertain  the  suitability  of  an  instrument  by  fitting  several 
to  the  ear,  it  is  of  advantage  to  have  an  associate  note  carefully  the 
shape  of  the  ear  and  the  direction  of  the  meatus,  in  order  to  secure  a 
better  conformity  of  the  stethoscope  to  the  anatomic  peculiarities  of 
the  individual.  My  own  preference  for  general  use  are  the  stethoscopes 
shown  in  Figs.  33  and  34. 

The  solid  tube  should  be  of  metallic  construction,  rather  than  of 
hard  rubber,  and  its  size  should  vary  from  four-sixteenths  to  five- 
sixteenths  of  an  inch  in  diameter. 

The  spring  of  the  instrument  may  be  of  steel,  or  consist  merely  of 
a  rubber  band.     It  is  desirable  that  the  spring  should  be  sufficient  to 


PHYSICAL    SIGNS 


force  the  ear-pieces  comfortably  within  the  meatus,  therefore  a  vari- 
ation in  its  strength  is  demanded  for  different  individuals.     There  are 


Fig.  34.- 


two  forms  of  adjustable  steel  springs,  one  of  which  should  invariably 
be  avoided.  This  is  the  thumb-screw,  which  is  rather  a  clumsy  con- 
trivance, and  precludes  the  removal  of  the  stethoscope  without  turning 


1  cun-e  of  the  metallic  tubes.     Note 


the  screw.  Such  a  device  is  objectionable,  for  it  prevents  a  continuous 
firm  pressure  of  the  ear-pieces  within  the  external  auditory  canal.  In 
another  form  of   adjustable  spring   the  attached  arms  slide  up  and 


AUSCULTATION  197 

down  the  solid  tube,  producing  a  corresponding  increase  or  diminu- 
tion of  the  pressure.  Objection  has  been  made  to  the  use  of  a  rubber 
band  lest  the  breath  of  the  examiner  induce  vibrations  leading  to  pos- 
sible confusion,  especially  with  beginners.  The  extraneous  sound  is  of 
but  slight  import,  and  is  present  only  when  the  rubber  bands  are  so 
small  in  size  as  to  permit  easy  vibration.  The  use  of  a  thick  rubber 
band  i.s  rarely  attended  by  this  trifling  annoyance. 

.loiiited  instruments  possess  no  advantage  and  are  objectionable, 
because  of  the  frequent  .slipping  of  the  parts. 

The  rubber  tubes  should  be  readily  flexible  in  order  to  permit  a 
quick  and  easy  adaptation  of  the  stethoscope  to  various  parts  of  the 
body  without  a  corresponding  change  in  the  position  of  the  examiner. 
This  is  particularly  important  in  the  examination  of  infants  or  chil- 
dren. If  the  tubing  is  of  small  diameter  and  unduly  pliable,  it  may 
collapse  or  kink  at  times  and  obstruct  the  sound  transmission.  If  the 
tubes  are  too  stiff  and  unyielding,  they  are  less  suitable  for  general  use 
and  are  more  likely  to  break  when  folded.  Small  apertures  are  often 
worn  through  the  wall  of  the  rubber  tube  from  folding  in  the  pocket. 
These  openings  frequently  escape  notice,  and  yet  permit  an  appreciable 
diminution  in  the  clearness  and  intensity  of  the  sounds.  The  length 
of  the  tubes  should  not  be  over  eight  to  ten  inches. 

The  bell  of  the  instrument  may  be  of  wood,  hard  rubber,  or  ivory. 
If  there  is  any  choice,  wood  seems  to  be  preferable.  At  the  present 
time  it  is  difficult  to  obtain  chest-pieces  of  this  material.  The  inner 
opening  of  the  chest-piece  should  correspond  in  size  to  the  rubber 
tubing,  while  the  distal  extremity  of  the  bell  should  have  a  diameter 
of  about  an  inch  and  a  half.  Chest-pieces  of  slightly  varying  size 
may  be  used  for  different  purposes,  the  small  bell  being  particularly 
applicable  to  children. 

Reference  has  previously  been  made  to  an  instrument  known  as  the 
Bowles  stethoscope,  which  is  especially  adapted  to  the  examination  of 
deep-seated  pulmonary  conditions.  One  of  its  distinguishing  character- 
istics is  the  shape  of  the  chest-piece,  which  resembles  a  shallow  cup  with 
a  diameter  of  about  two  and  one-half  inches.  Across  the  cup  extends 
a  hard-rubber  diaphragm,  which  may  be  covered,  if  desired,  by  thin  rub- 
ber, to  prevent  slipping  upon  the  skin.  Although  the  breath-sounds  are 
intensified  somewhat,  there  is  often  an  accompanying  change  in  quality. 
No  marked  advantage  attends  the  employment  of  this  instrument,  save 
in  exceptional  cases.  It  is  sometimes  a  matter  of  convenience  to 
examine  under  the  .shirt,  but  it  is  very  seldom  that  a  satisfactory  exami- 
nation cannot  be  made  with  an  ordinary  stethoscope.  The  method  of 
dropping  the  chest-piece  attached  to  a  long  tube  clown  the  back  when 
listening  over  an  invisilile  area  is  hardly  in  accord  with  the  modern 
conception  of  clinical  exactness.  This  instrument  is  quite  unadapted 
to  exploration  of  the  apices  or  examination  of  greatly  emaciated  people, 
on  account  of  the  large  diameter  of  the  chest-piece.  Another  serious 
objection  is  the  fact  that  the  abrupt  inward  curve  of  the  proximal 
extremities  is  unsuited  to  most  individuals.  The  monaural  stetho- 
scopes are  very  little  used  in  this  country  at  the  present  time,  and 
have  no  advantage  over  the  binaural,  while  manifestly  possessing  many 
of  the  objections  peculiar  to  the  direct  method. 


198  PHYSICAL    SIGNS 


RULES  FOR  THE  PERFORMANCE  OF  AUSCULTATION 

Intelligent  auscultation  demands  the  systematic  observance  of 
certain  procedures  on  the  part  of  the  patient  and  the  examiner.  As 
far  as  the  patient  is  concerned,  the  most  important  consideration 
relates  to  the  manner  of  breathing.  It  is  desirable  that  the  patient 
should  inspire  rather  forcefully  in  order  to  increase  somewhat  the 
intensity  of  breath-sounds  and  thus  afford  the  examiner  an  opportunity 
to  study  other  characteristics.  Simply  telling  the  patient  how  to 
breathe  is  not  sufficient,  as  a  rule.  More  satisfactory  results  are  obtained 
by  illustrating  personally  the  desired  manner  of  respiration.  Difficulty 
is  often  experienced,  particularly  with  nervous  people,  in  securing  a 
proper  method  of  breathing  during  examination.  Under  these  cir- 
cumstances recourse  should  be  taken  to  a  single  slight  cough  preceding 
inspiration.  Patients  should  be  instructed  to  breathe  with  the  mouth 
slightly  open  and  to  avoid  inhaling  through  the  nostrils.  They  should 
be  taught  to  take  moderately  quick,  forcible  breaths,  and  after  a  mom- 
entary pause  to  exhale  completely,  but  without  violence.  This  is  rarely 
understood  at  first,  unless  demonstrated  by  the  examiner.  Some  patients 
endeavor  to  inhale  slowly  and  deeply  in  order  to  secure  as  full  an  inspi- 
ration as  possible.  Others  are  prone  to  give  short,  jerky  inspirations, 
which  are  fully  as  undesirable.  It  is  necessary  that  a  complete 
expiration  should  be  effected  in  order  to  permit  subsequently  a  proper 
inspiration.  Blowing  or  audible  respiratory  sounds  should  be  avoided 
as  much  as  possible.  A  moderately  sharp  inspiration,  held  momentarily, 
the  patient  exhaling  without  noise,  offers  the  best  opportunities  for  sat- 
isfactory auscultation. 

The  rules  to  be  observed  by  the  examiner  are  equally  important 
and  more  a  matter  of  detail. 

A  correct  position  of  the  physician  is  essential  for  the  best  results. 
The  head,  under  all  circumstances,  should  be  erect,  and  the  upper  part 
of  the  body  not  too  much  inclined.  Bending  over  the  patient  should 
be  avoided  in  order  to  prevent  the  retention  of  blood  in  the  head, 
which  produces  more  or  less  discomfort  and  appreciably  dulls  the  sense 
of  hearing.  Under  all  circumstances  the  examiner  must  be  perfectly 
comfortable.  If  the  patient  is  sitting,  the  physician  .should  sit  also, 
but  when  examining  the  lower  portions  of  the  chest,  may  rest  upon  one 
knee.  When  the  patient  is  in  bed,  it  is  essential  that  the  examiner 
should  so  adjust  his  position  as  to  avoid  the  disadvantages  incident  to 
prolonged  stooping. 

The  physician,  when  comparing  opposite  sides  of  the  chest,  should 
always  examine  si/mmetric  regions.  The  various  parts  of  the  thorax 
should  be  explored  in  accordance  with  a  systematic  method,  as  opposed 
to  the  haphazard  or  roving  auscultation  so  often  observed.  A  diagnosis 
as  to  the  phy.sical  conditions  involving  one  side  should  not  be  reached 
without  first  comparing  the  sounds  heard  upon  the  other,  no  matter 
how  conclusive  the  auscultatory  evidences  may  appear. 

The  bell  of  the  stethoscope  should  be  pressed  upon  the  chest-wall 
with  a  uniform  degree  of  firmness,  as  distinct  differences  may  fail  of 
recognition  through  neglect  to  observe  Tliis  ]irc(;iiitinn.  The  raising  of 
a  portion  of  the  instrument  from  the  chest-wall  during  a  hasty  or  care- 
less examination  effectual!}'  prevents  the  conduction  of  intrathoracic 
sounds  to  the  ear. 


AUSCULTATION  199 

Especial  care  should  be  taken  to  avoid  movement  of  the  fingers 
upon  the  bell  of  the  stethoscope  when  applied  to  the  chest.  It  is  sur- 
prising to  what  an  extent  a  slight  motion  of  the  fingers  may  produce 
sounds  obscuring  the  respiratory  murmur  or  simidating  rales.  A  fine 
raised  point  should  project  from  the  top  of  the  bell,  upon  which  the  ball 
of  the  thumb  may  rest  to  hold  the  instrument  in  place,  no  other  portion 
of  the  hand  or  fingers  being  in  touch  with  the  stethoscope.  For  some 
reason  this  small  projection  is  not  found  upon  many  stethoscopes  at  the 
present  time. 

Very  appreciable  noises,  sufficient  to  produce  incorrect  results, 
may  be  caused  by  the  condition  of  the  skin.  Reference  is  made  to  the 
abundant  growth  of  hair,  the  existence  of  scaly  eruptions,  and  the 
extreme  dryness  of  the  skin  in  certain  conditions.  It  would  seem  that 
these  extraneous  sounds,  resembling  dry  or  fine  moist  rales,  might  be 
avoided  by  increasing  the  pressure  of  the  instrument  against  the  skin 
and  by  using  every  precaution  to  avoid  the  slightest  sliding  movement. 
While  such  noises  may  often  be  excluded,  the  fact  remains  that  in  some 
instances  they  may  be  heard  despite  the  observance  of  a  rigid  technic. 
My  custom  in  such  cases  is  either  to  rub  a  little  vaselin  upon  the  skin 
or  to  apply  soap  with  a  wet  towel. 

One  of  the  most  important  desiderata  for  the  examiner  is  to  acquire, 
as  far  as  possible,  the  power  of  concentration.  He  should  listen  to  the 
intrathoracic  sounds  conducted  through  the  stethoscope  and  be  oblivious 
to  all  noises  from  without.  This  ability  can  be  developed  to  a  great 
extent  even  in  the  midst  of  much  external  confusion,  although  it  is,  of 
course,  decidedly  better  if  the  examination  can  be  conducted  in  quiet. 

AUSCULTATION  OF  THE  NORMAL  CHEST 
This  includes  listening  to  the  sounds  produced  by  the  breath  and 
by  the  voice. 

Sounds  Produced  by  the  Breath. — Auscultation  of  the  breath- 
sounds  involves  a  minute  comparison  of  inspiration  with  expiration, 
the  general  respiratory  features  being  found  to  present  striking  differ- 
ences. They  are  subject  to  analysis  according  to  intensity,  pitch,  qual- 
ity, ;m(l  <lin;ition.  It  is  essential  to  recognize  thoroughly  these  four 
<li;ii:iitciistiis  of  inspiration,  and  to  compare  them  with  the  intensity, 
pitch,  i|u:ility,  and  duration  of  expiration. 

There  is  a  type  of  respiration  called  "vesicular"  breathing  which  is 
heard  over  the  normal  chest.  This  presents  differences  in  cei'tain  parts 
of  the  thorax  precisely  as  regional  percussion  changes  are  observed. 
There  is  another  distinct  variety  of  respiration,  known  as  bronchial  or 
tubular  breathing,  which  may  be  heard  over  the  larynx  or  trachea  in 
health.  The  peculiar  characteristics  noted  are  identical  to  the  sounds 
produced  in  the  chest  in  the  midst  of  certain  pathologic  conditions. 
Inasmuch  as  all  respiratory  sounds  conform  more  or  less  to  one  or  the 
other  of  these  types,  and  sometimes  to  both  jointly,  it  has  been  found 
sharply  between  vesicular  and  bronchial 
•tter  for  the  student  to  study  the  character- 
\iX  liefore  those  of  the  vesicular  type.  The 
i>un(is  in  the  former  are  more  intense,  with 
iiccs  in  ]5itch  and  duration,  makes  it  some- 
r  to  compare  the  sounds  of  inspiration  with 


expedient  to  flisciii 

•      ( 

breathing.     It  i>  usi 

Klllv    1m 

istics  of  bron<'hi:il   li 

ivallnii 

fact  that  the  I'c^pii- 

lt<ll\-    S( 

sharply  ucccni  imicil 

iliffcic 

what  easier  tni-  the  1: 

leginne 

those  of  expii-ation. 

200 


PHYSICAL    SIGNS 


Bronchial  Respiration. — With  the  stethoscope  placed  over  the 
trachea  or  larynx  the  student  at  once  recognizes  an  inspiratory  sound, 
more  or  less  intense,  high  in  pitch,  and  of  a  quality  which  may  be 
described  as  tubular,  similar  to  that  produced  by  blowing  through  a 
tube.  The  duration  is  somewhat  less  than  the  length  of  time  consumed 
by  the  act  of  inspiration.  In  other  words,  the  sound  does  not  last  until 
the  very  end  of  inspiration,  the  pause  taking  place  just  before  the  act 
is  completed.  The  expiration  is  still  more  intense  than  the  inspiration, 
of  relatively  higher  pitch,  of  the  same  tubular  cjuality,  and  much  longer 
in  duration.  As  the  quality  is  the  same  in  inspiration  and  expiration, 
the  increased  intensity,  higher  pitch,  and  prolonged  expiration  form 
the  distinguishing  characteristics  of  this  type  of  respiration. 

It  is  necessary  that  these  auscultatory  facts  should  be  committed 
to  memory.  To  this  end  a  diagrammatic  representation  of  the  sounds 
in  bronc'hial  breathing  is  of  some  value  in  emphasizing  the  differences 
of  inspiration  and  expiration.  The  method,  as  suggested  by  Dr.  Gar- 
land, which  I  have  employed  for  years,  is  .shown  below.  The  minus  sign 
being  associated  with  inspiration  and  the  plus  sign  with  expiration, 
enables  the  student  more  definitely  to  appreciate  the  sounds  of  bron- 
chial breathing.  A  comparison  of  this  with  the  diagram  designed  to 
illustrate  the  sounds  of  inspiration  and  expiration  in  vesicular  breathing 
affords  a  simple  way  to  impress  the.se  relations  upon  the  beginner: 

BRONCHIAL   RESPIRATION 


Inspiration     .    .    . 

Intensity. 

Pitch. 

Duration. 

Quality. 

- 

- 

- 

Tubular. 

E.\piration      .    .    . 

+ 

+ 

+ 

Tubular. 

Vesicular  Respiration. — The  term  "vesicular  respiration"  is 
applied  to  that  type  of  breathing  recognized  upon  auscultation  of  the 
normal  chest.  It  is  used  to  designate  the  breath-sounds  reaching  the 
ear  of  the  auscultator  through  the  final  medium  of  the  air-vesicles,  just 
as  bronchial  respiration  is  applied  to  the  sounds  emanating  from  a  bron- 
chial tube  or  transmitted  therefrom  through  consolidated  lung.  It  must 
not  be  assumed  that  a  strictly  arbitrary  or  ideal  type  of  vesicular  respi- 
ration is  applicable  to  all  people,  for  each  healthy  person  furnishes  his 
own  standard.  Individual  differences  obtain  with  regard  to  the  intensity 
of  breath-sounds,  referable  to  the  age,  the  thickness  of  the  muscles  or 
overlying  soft  parts,  and  the  manner  of  breathing.  An  analytic  com- 
parison, however,  of  inspiration  and  expiration  discloses  the  fact  that 
certain  definite  and  unvarying  relations  obtain  among  all  healthy 
persons. 

Selecting  as  a  suitable  site  for  beginning  auscultation  the  region 
below  the  right  clavicle  or  in  either  axilla,  the  essential  features  of  this 
type  of  breathing  are  easily  recognized.  The  inspiration  is  of  variable 
intensity,  and  the  pitch  is  low  as  compared  with  that  of  inspiration 
during  bronchial  respiration.  The  quality,  for  the  sake  of  convenience, 
may  be  stated  to  be  vesicular,  although  described  by  some  as  breezy. 


AUSCULTATION  201 

from  its  resemblance  to  the  rustling  of  leaves  agitated  by  the  wind. 
The  sound  must  be  heard  to  be  appreciated  perfectly,  and  is  best 
designated  as  vesicular,  rather  than  by  analogous  terms.  The  duration 
of  the  sounil  during  inspiration  is  as  long  as  the  act  itself,  there  being  no 
])ause  1  )et  ween  inspiration  and  expiration  unless  the  breath  is  voluntarily 
hekl  l>y  the  ]:iatient. 

In  ex])irHt  1(111  the  intensity  is  notably  less  than  that  of  inspiration, 
and  the  ]iiirli  i.-  likewise  lower.  The  quality  does  not  partake  of  the 
same  breezy  chuructcr  of  inspiration,  and  for  lack  of  a  better  terminology 
may  be  regarded  as  blowing  in  type.  The  duration  is  much  shorter 
than  the  act  of  expiration,  and  is  less  than  the  time  consumed  in  inspir- 
ation. Without  attempting  a  detailed  explanation  of  the  reasons  why 
these  differences  exist  between  inspinition  and  expiration,  it  is  sufficient 
to  impress  upon  the  beginner  the  lad  tliat  they  actually  occur.  Le  Fevre 
has  admirably  explainetl  that  in  nispii'atidn,  which  is  an  active  function, 
the  vibrations  are  conducted  through  the  column  of  inspired  air  in  the 
bronchial  tubes  to  the  air-vesicles,  the  sound  being  also  traiisniitted  by 
the  ever-increasing  tension  of  the  bronchial  and  pulmonary  tissues 
during  the  progress  of  inspiration.  Expiration,  on  the  other  hand,  is 
a  passive  motion,  the  direction  of  the  air-current  being  away  from  the 
ear  of  the  examiner,  and  the  tension  of  the  tissues  constantly  diminish- 
ing as  expiration  advances,  thus  minimizing  the  sound  transmission. 

VESICULAR    RESPIRATION 


Inspiration     .   .    . 

Intensity. 

Pitch. 

Duration. 

Quality. 

-1- 

+ 

+ 

Vesicular. 

Expiration      .    . 

- 

- 

- 

Blowing. 

Some  clinicians  do  not  recognize  essential  differences  in  the  quality  of 
inspiration  and  expiration,  and  others  describe  the  expiratory  sounds  as 
differing  only  in  increased  harshness.  To  my  mind  the  quality  of  the 
expiratory  sound  differs  somewhat  from  the  inspiratory,  but  not  in  the 
way  of  greater  harshness.  The  term  appears  to  be  an  unfortunate  one, 
for  harshness  often  conveys  to  the  mincl  an  idea  of  increased  intensity. 
This  is  diminished  invariably  in  expiration,  and  for  this  reason,  if  for 
no  other,  it  is  better  not  to  employ  the  word  "harsh"  to  describe  the 
quality  of  the  expiratory  sound.  This  may  properly  be  applied  to  a 
certain  modification  of  normal  vesicular  respiration,  often  designated 
as  puerile  breathing,  which  refers  to  increased  intensity  rather  than  to 
other  essential  deviations  from  the  normal.  Employing  a  diagrammatic 
illustration  of  vesicular  resj^iration  the  plus  mark,  in  contrast  to  bron- 
chial breathing,  will  lie  found  to  denote  the  intensity,  pitch,  and  dur- 
ation of  inspiration  rather  than  of  expiration. 

Regional  Differences. — The  most  important  modification  of  vesicular 
respiration  is  observed  at  the  apices.  Upon  examination  of  either  lung 
at  the  apex  the  inspiration  is  recognized  as  less  intense  than  below  the 
clavicle,  the  pitch  higher,  the  quality  less  vesicular,  and  in  .some  cases 
the  duration  not  quite  so  long.     The  expiratory  sound  in  this  region 


202  PHYSICAL    SIGNS 

is  more  intense  than  in  the  lower  parts  of  the  chest,  the  pitch  higher, 
the  quality  a  modification  of  the  blowing  and  the  tubular,  and  the  dura- 
tion somewhat  prolongeti.  The  change  from  the  vesicular  and  the 
blending  with  the  bronchial  \'ariety  in  some  cases  may  be  so  pronounced 
as  to  justify  the  appellation  "  bronchovesicular  respiration." 

It  is  important  to  cinpluifiize  the  jact  that  there  is  a  normal  disparity 
between  the  tivo  apices,  the  modification  of  the  vesicular  tjipe  and  the 
approach  to  the  bronchial  being  more  marked  upon  the  right  side  than 
upon  the  left.  At  the  right  apex  the  inspiration  is  less  intense  than 
at  the  left,  the  pitch  higher,  and  the  equality  less  vesicular.  The  expi- 
ration is  more  intense,  of  higher  pitch,  antl  more  prolonged  upon  the 
right  side.  This  physiologic  difference  in  the  auscultatory  signs  at  the 
two  apices  is  a  matter  of  the  utmost  importance,  and  .should  constantly 
be  borne  in  mind  in  order  to  avoid  possible  mistakes  in  the  diagnosis  of 
incipient  apical  tuljerculosis.  A  slight  change,  as  described,  at  the  right 
ajiex  may  not  be  possessed  of  any  special  diagnostic  significance,  while 
a  diminished  intensity,  elevation  of  pitch,  and  diminished  vesicular 
cjuulity  of  inspiration,  with  a  corresponding  increase  of  intensity,  still 
higher  pitch,  and  prolongation  of  expiration  upon  the  left  side  con- 
stitute positive  evidence  of  a  pathologic  condition.  Many  patients  have 
been  sent  to  a  distant  clime  on  account  of  a  supposed  right  apical 
tuberculosis,  although  upon  examination  there  was  found  but  an  exagger- 
ation of  the  physiologic  disparity  between  the  two  sides,  without  even 
subjective  evidence  of  tuljerculous  invasion.  Some  presenting  unmis- 
takable evidence  of  constitutional  impairment  have  been  sent  away 
from  home  with  a  diagnosis  of  a  tuberculous  lesion  at  the  right  apex, 
yet  the  signs  of  active  infection  were  confined  to  other  regions.  These 
inaccm-acies  sometimes  occur  for  the  reasons  that  physicians  are  in  the 
habit  of  examining  more  carefully  at  the  apices  than  in  other  places; 
that  the  normal  difference  between  the  two  sides  is  often  unappreci- 
ated; and  that  modifications  of  the  normal  breath-sounds  are  frequently 
recognized  at  the  right  apex,  while  in  other  parts  adventitious  sounds 
or  rales  are  entirely  overlooked  because  of  neglect  to  utilize  cough,  which 
constitutes  a  \'aluable  aid  in  auscultation.  An  appreciable  retraction 
of  the  apex,  with  change  in  percussion  resonance,  is  often  of  material 
aid  in  forming  a  correct  conclusion.  The  recognition  of  moisture  at  one 
apex  following  a  cough  clears  all  tloutit  as  to  the  presence  or  absence  of 
abnormal  conditions.  In  the  axillary  or  infra-axillary  region  the  intensity 
of  the  inspiration  is  quite  as  loud  as  below  the  clavicle,  being  greater  in 
these  two  places  than  in  any  other  part  of  the  chest.  The  pitch,  if 
anything,  is  lower  than  in  the  infracla\-icular  region,  and  the  quality 
somewhat  more  vesicular.  There  is  no  difference  between  the  two  sides 
in  this  region. 

Over  the  scapulse  the  sounds  of  inspiration  and  expiration  are  less 
intense  than  in  almost  any  other  locality.  Differences  in  pitch,  quality, 
and  duration  are  le.ss  easily  recognized  in  this  region  because  of  the 
(liniinished  intensity.  There  is  no  disparity  to  be  recognized  between 
tlie  two  sides. 

In  the  interscapular  spaces  the  intensity  of  the  breath-sounds  is 
nearly  as  great  as  in  the  infraclavicular  or  axillary  regions.  There  exists 
a  slight  difference  lietween  the  two  sides,  similar  to  the  disparity  noted 
at  the  apices,  though  less  in  degree. 

Normal  Voice-sounds. — In  describing  the  soimds  of    respiration. 


AUSCULTATION  203 

attention  was  directed  to  the  types  of  breathing  heard  over  the  trachea 
and  the  chest.  In  the  same  manner  the  sound  produced  by  the  spoken 
voice  should  be  studied  with  reference  to  its  characteristics  when  heard 
over  the  trachea  and  over  the  normal  chest. 

Vocal  Resonance  over  the  Larynx  or  Trachea. — If  the  stethoscope  is 
applied  to  the  skin  and  the  patient  directed  to  say  "  ninety-nine, "  there 
is  conveyed  to  the  ear  of  the  examiner  a  disagreeable  sensation  of  shock 
or  fremitus,  associated  with  a  distinct  appreciation  of  concentration  and 
nearness.  The  sound  is  sometimes  intense,  but  this  is  subject  to  some 
variation.  These  essential  features  are  analogous  to  the  sound  obtained 
over  the  chest  in  certain  states  of  disease.  A  fuller  description  of  the 
sound  of  the  spoken  voice,  to  which  the  term  "bronchophony"  is  ap- 
plied, will  be  reserved  for  subsequent  pages. 

Vocal  Resonance  over  Normal  Lung. — With  the  stethoscope  placed 
firmly  against  the  chest  during  phonation,  the  auscultator  is  enabled  to 
distinguish  a  vibration,  although  receiving  no  impression  of  shock  or 
fremitus.  There  is  no  suggestion  of  concentration  or  nearness,  the 
sounds  appearing  diffused  and  as  if  coming  from  a  distance  rather  than 
emanating  directly  under  the  stethoscope.  The  vibration  is  found  to 
increase  directly  with  the  loudness  and  harshness  of  the  spoken  voice, 
the  le.sser  thickness  of  the  soft  parts,  and  the  firmer  pressure  of  the 
instrument  against  the  skin.  Men  afford  much  better  illustrations  of  the 
vocal  resonance  than  women.  The  resonance  varies  in  different  portions 
of  the  chest,  it  being  more  pronounced  at  the  apices  than  elsewhere, 
and  more  upon  the  right  side  than  upon  the  left. 

The  Whispered  Voice. — The  stuilent  should  listen  to  this  over  the 
lar}mx  and  the  normal  chest,  the  sountls  heard  in  the  former  location 
resembling  closely  those  recognized  in  the  presence  of  certain  pathologic 
changes  in  the  lung.  It  will  be  understood  that,  in  whatever  region 
auscultation  is  practised,  the  whispered  voice  can  differ  but  little  from 
the  sound  of  expiration.  As  the  only  difference  relates  to  intensity, 
but  brief  reference  need  be  made  to  the  characteristics  of  the  whispered 
voice.  Over  the  trachea  the  sound  is  shrill,  high  pitched,  more  or  less 
intense,  and  tulnilar  in  quality,  suggesting  a  current  of  air  driven  forci- 
bly through  a  tube.  Occasionally,  while  listening  in  this  region,  it  is  easy 
to  recognize  the  words  uttered  by  the  patient.  During  auscultation 
of  the  normal  chest  it  is  often  impossible  to  distinguish  the  sound  of 
the  whispered  voice.  If  recognized  at  all,  the  pitch  is  low  and  the 
quality  blowing.  At  most  an  impression  is  received  of  a  faint,  low- 
pitched,  whispered  sound,  without  ability  to  recognize  what  is  said  by 
the  patient.  The  same  regional  differences  regarding  the  whispered 
voice  are  found  to  exist  as  obtain  with  the  spoken  voice. 

AUSCULTATION  IN  THE  MIDST  OF  PATHOLOGIC  CONDITIONS 

The  study  of  auscultation  in  disease  should  be  conducted  with 
reference  to  the  breath-sounds  and  those  of  the  spoken  voice,  both 
aloud  and  whispered.  Auscultation  of  the  breath-sounds  includes 
two  distinct  considerations — pathologic  modifications  of  the  normal 
respiratory  sounds,  and  adventitious  sounds,  commonly  described  as 
rales,  which  are  never  present  in  health,  save  in  .senile  atelectasis. 

Modifications  of  Normal  Respiratory  Sounds. — Just  as  the 
study  of  the  breath-sounds  in  health  involves  analytic  comparisons  of 


204  PHYSICAL    SIGNS 

the  intensity,  pitch,  quality,  and  duration  of  inspiration  with  expira- 
tion, so  in  the  midst  of  morbid  conditions  the  same  form  of  procedure 
should  be  emploj'ed  in  order  to  detect  deviations  from  the  normal. 
Rather  than  attempt  to  classify  the  various  abnormal  types  of  breath- 
ins  by  the  use  of  descriptive  names,  as  "emphysematous  breathing," 
"asthmatic  breathing,"  "cog-wheel  breathing,"  etc.,  which  method 
is  often  employed,  I  will  group  the  various  pathologic  modifications 
with  reference  to  changes  in  intensity,  pitch,  quality,  and  duration. 
This  would  seem  to  be  the  more  simple  and  natural  method,  and  it 
is  lioped  will  appeal  to  students  in  being  easily  understood. 

Changes  in  Intensity. — This  may  be  entirely  absent,  somewhat 
chminished,  or  perceptibly  increased. 

It  should  be  understood  that  in  many  instances  changes  of  intensity 
bear  not  the  slightest  relation  to  differences  in  pitch,  quality,  or  duration. 
The  sounds,  however,  may  be  so  feeble  and  faint  as  to  afford  no  oppor- 
tunity for  further  study. 

Entire  absence  oj  breath-sounds  may  result  from  the  same  causes 
which,  if  present  to  a  less  extent,  merely  suffice  to  produce  a  diminution 
of  intensity.  Complete  suppression  of  the  respiratory  sounds  may  take 
place  in  pleurisy  with  effusion,  closed  pneumothorax,  pneumopyothorax, 
pneumonic  consolidation,  entire  occlusion  of  primaiy  bronchi,  either 
from  aneurysm  or  mediastinal  ulaiids,  in  pulmonary  edema,  or  the  fill- 
ing of  air-vesicles  with  extia,\a-atc(l  blood. 

Diminution  of  Intentuhi  nj  R,  spiratort/  Sounds.-— The  breath-sounds 
may  be  enfeebled  by  reason  of  changes  acting  upon  the  outer  or  inner 
walls  of  the  bronchi,  accumulations  within  the  bronchi,  pathologic  con- 
ditions in  the  lung  tissue,  within  the  pleural  cavity,  or  in  the  wall  of 
the  thorax,  involvement  of  the  nerves,  and  influences  preventing  the 
descent  of  the  diaphragm. 

The  outer  walls  of  the  bronchi  may  be  subject  to  compression  from 
mediastinal  glands,  aneurysms,  new-growths,  or  greatly  dilated  hearts. 

The  inner  walls  are  affected  by  catarrhal  conditions  inducing  a 
thickening  of  the  mucous  membrane  or  involving  exudative  processes 
sufficient  partially  to  occlude  the  lumen. 

An  accumulation  of  thick  tenacious  mucopus  may  obstruct  the  caliber 
of  the  tube  to  such  an  extent  as  to  diminish  the  intensity  of  the  breath- 
sounds.  The  presence  of  blood  or  serous  secretions  within  the  finer 
tubes  may  produce  a  like  result. 

The  most  important  change  in  the  lung  resulting  in  an  enfeeblement 
of  the  respiratory  sounds  is  the  lessened  elasticity  of  tissue  taking  place 
in  long-standing  emphy.sema.  In  early  or  so-called  compensatory 
emphysema  the  tension  of  the  pulmonary  tissues  is  increased  and  the 
breath-sounds  are  correspondingly  more  intense,  but  as  the  emphysema 
becomes  chronic,  a  reverse  effect  is  noted.  Through  the  loss  of  elas- 
ticity or  retractile  power  the  respiratory  excursion  is  gradually  dimin- 
ished. Reduction  of  inten.sity  forms  one  of  the  chief  characteristics  of 
the  emphysematous  type  of  breathing.  With  this  there  are  associated 
definite  changes  in  the  duration,  the  inspiratory  .sound  being  shortened 
and  the  expiration  prolonged.  The  shortening  of  in.spiration  takes 
place  at  the  beginning  of  the  inspiratory  act  rather  than  at  the  end, 
as  is  found  in  bronchial  breathing.  There  are  no  changes  recognized 
as  regards  pitch  in  this  form  of  respiration,  neither  is  the  quality  affected 
materially,  although  the  vesicular  character  is  somewhat  less  distinct. 


AUSCULTATION  _  205 

There  is  another  form  of  breathing,  similar  in  many  respects  to  the 
emphysematous  variety,  occurring  in  the  course  of  asthma.  This 
develops  as  a  result  of  spasm  of  the  muscular  fibers  encircling  the 
bronchial  tubes.  Like  emphysematous  breathing,  the  inspiration  is 
shortened  at  the  beginning  of  the  inspiratory  act  and  the  expiration 
is  prolonged,  l)ut  the  intensity  is  usually  greater  than  in  the  purely 
emphj'sematous  type.  There  is  recognized  no  change  in  pitch,  and  it  is 
very  diflicult  to  appreciate  changes  in  C(uality,  as  loud  adventitious 
sounds  usually  obscure  other  elements.  The  rales  occur  both  during 
inspiration  and  expiration,  are  dry  in  character,  and  are  called  either 
sibilant  or  sonorous,  respectively,  according  as  they  are  high  or  low  in 
pitch.  Diminution  of  respiratory  sounds  may  also  be  occasioned  by 
consolidation,  either  partial  or  complete,  as  in  pneumonia,  pulmonary 
tuberculosis,  compression  of  lung  from  pleural  effusion,  new-growths, 
and  hemorrhagic  infarcts. 

The  changes  within  the  pleural  cavity  capable  of  reducing  the  inten- 
sity of  breath-sounds  relate  to  the  presence  of  liquid  or  air,  as  in  pleural 
effusion,  hydrothorax,  pneumothorax,  and  pneumopyothorax.  In 
pleurisy  with  but  little  effusion  the  liquid  remains  at  the  base  of  the 
pleural  cavity,  reducing  slightly  the  intensity  of  the  respiratory  sounds 
in  this  region.  As  the  effusion  becomes  more  extensive  it  is  molded 
around  the  lung,  interposing  between  it  and  the  chest-wall  a  layer  of 
liquid  through  which  the  respiratory  sounds  must  pass  before  reaching 
the  ear  of  the  examiner.  In  hydrothorax  or  dropsy  of  the  pleural  cavity 
the  liquid  remains  at  the  dependent  portion  of  the  chest  and  obscures 
the  breath-sounds  in  this  locality.  If  air  is  present  in  the  pleural 
cavity,  the  diminution  of  intensity  is  dependent  to  a  great  extent  upon 
the  existing  type  of  pneumothorax.  In  the  closed  \;uict>'  thf  l)rc;ith- 
sounds  are  diminished  or  absent,  but  if  there  is  a  ficc  opcniim  intu  a 
bronchial  tube,  varying  degrees  of  intensity  are  exhiliitc<l.  ruder  .-luli 
circumstances  characteristic  changes  in  quality,  pitch,  antl  ckuation  are 
recognized,  to  be  described  later  as  constituting  amphoric  and  cavernous 
respiration.  Among  other  conchtions  involving  the  pleura,  causing 
enfeeblement  of  respiratory  sounds,  are  extensive  pleuritic  adhesions 
with  marked  fibrous  tissue  proliferation  following  long-standing  chronic 
pleurisies. 

An  inflexible  bony  thorax  and  great  thickness  of  the  soft  parts  may 
also  reduce  the  intensity  of  breath-sounds. 

A  like  result  is  caused  by  unilateral  paralysis  of  the  muscles  of  res- 
piration, or  a  severe  intercostal  neuralgia,  retarding  respiratory  excur- 
sion. 

Complete  descent  of  the  diaphragm  may  be  prevented  by  partial 
paralysis  of  the  diaphragm,  the  presence  of  extensive  abdominal  dropsy, 
severe  peritonitis,  and  marked  abdominal  distention  from  pregnancy  or 
new-growth. 

Increased  Intensitii  of  Breath-sounds. — The  respiratory  sounds  are 
more  or  less  increased  in  children  and  in  thin-chested  adults.  The 
exaggerated  intensity  is  so  constant  in  children  as  to  suggest  the  appella- 
tion of  "puerile  respiration,"  which  bears  no  relation,  however,  to  pitch 
or  quality.  The  sounds  are  notably  intensified  in  compensatory  or 
supplemental  breathing,  which  occurs  in  one  lung  when  a  considerable 
area  of  pulmonary  tissue  in  the  other  is  effectually  incapacitated. 
This  may  take  place  as  a  result  of  pneumonia,  pneumothorax,  pleurisy 


206  PHYSICAL    SIGNS 

with  large  effusion,  or  extensive  fibroid  change.  Under  such  con- 
ditions the  respiratory  needs  of  the  individual  are  supplied  only  by  the 
compensatory  activity  of  the  unaffected  lung.  With  increased  tension 
of  the  pulmonary  tissues  and  with  wider  respiratoiy  excursions  the 
intensity  of  the  breath-sounds  is  necessarily  increased. 

Changes  in  Pitch  and  Quality. — Inasmuch  as  deviations  from 
the  normal  pitch  almost  invariably  accompany  changes  in  quality,  it 
is  well  to  consider  these  jointly.  Coincident  with  changes  in  pitch  and 
quality  there  also  occur  certain  variations  of  rhythm  and  duration.  In 
the  forms  of  respiration  now  to  be  described  the  changes  in  pitch  and 
quality  constitute  the  chief,  though  not  the  sole,  distinguishing  char- 
acteristics. Deviations  from  the  normal  in  duration  and  rhythm  will 
be  discussed  subsequently.  Changes  in  pitch  and  quality  are  found  in 
bronchial  breathing,  bronchovesicular  breathing,  cavernous  breathing, 
amphoric  breathing,  and  metamorphosing  respiration. 

Bronchial  Respiration. — A  description  of  bronchial  breathing  has 
been  given  on  p.  200,  in  connection  with  the  type  of  respiration  heard 
during  auscultation  over  the  trachea  or  larynx  in  health.  The  character- 
istics of  the  breath-sounds  in  that  location  were  said  to  be  identical  with 
those  recognized  in  the  thorax  in  certain  states  of  ili-sease.  The  patho- 
logic condition  capable  of  producing  this  type  of  breathing  in  the  chest  is 
consolidation  of  lung,  although  differing  degrees  of  consolidation  produce 
modified  types  of  bronchial  breathing.  It  is  possilile  that  the  consoli- 
dation may  be  so  extreme  as  to  prevent,  in  exceptional  cases,  any  appre- 
ciation of  breath-sounds  whatever,  while  in  others  it  may  be  insufficient 
to  produce  the  pure  form  of  bronchial  respiration.  The  consolidation 
commonly  results  from  pneumonia,  pulmonary  tuberculosis,  and  com- 
pression of  lung  from  extensive  pleural  effusion.  It  is  well  to  emphasize 
the  fact  that  the  intensity  of  breath-sounds  bears  no  absolute  relation 
to  the  changes  in  pitch,  quality,  and  duration.  The  respiration  may  be 
no  less  bronchial  by  virtue  of  the  fact  that  the  sound  of  both  inspiration 
and  expiration  is  enfeebled.  The  tubular  quality  of  both,  the  high 
pitch  of  inspiration,  and  the  still  higher  of  expiration,  the  slight  short- 
ening of  inspiration  occurring  at  the  end  of  the  inspiratory  act,  and 
the  marked  prolongation  of  the  expiration,  with  its  relatively  increased 
intensity,  are  the  chief  points  to  be  borne  in  mind. 

Bronchoreaicular  Respiration. — This  form  of  breathing  is  described 
by  some  as  a  combination  of  a  purely  vesicular  inspiration,  with  an 
expiration  of  bronchial  type.  In  order  to  avoid  unnecessary  confusion, 
such  designation  should  bp  restrirted  in  its  application  to  one  of  the 
varieties  of  metamorpho<i II i:  rc~|iii:it  ion.  It  i~  Ik  tier  to  regard  broncho- 
vesicular respiration  as  a  riiiiiliiiuiiiiiii  of  till-  \i-i(iilar  and  the  lironchial 
varieties,  both  as  regarils  in.spirutiuu  and  t'X))iratioii,  as  was  so  admirably 
explained  in  1856  by  Flint,  whose  classic  description  has  never  been 
equaled. 

The  inspiration  may  l^e  neither  distinctly  vesicular  nor  bronchial  in 
quality.  It  is  of  variable  intensity,  of  comparatively  low  pitch  in  propor- 
tion as  the  vesicular  predominates  over  the  bronchial  character,  and 
conversely  of  high  pitch  as  the  bronchial  quality  is  more  pronounced. 
The  expiration  approaches  a  tubular  quality,  with  corresponding  increase 
of  intensity,  prolongation  of  duration,  and  elevation  of  pitch.  This 
form  of  breathing  is  neither  purely  vesicular  nor  bronchial,  the  two 
types  being  blended  in  such  a  manner  as  to  render  it  impossible  to 


AUSCULTATION  207 

separate  the  distinctly  broncliial  from  the  clearly  vesicular,  either  in 
inspiration  or  expiration.  During  auscultation  at  the  apices  in  health, 
and  particularly  upon  the  right  side,  the  respimtory  sounds  suggest  a 
bronchial  element,  although  partaking  strongly  of  the  characteristics 
of  the  vesicular  type.  In  disease  bronchovesicular  respiration  is  occa- 
sioned by  partial  consolidation,  either  from  pneumonia,  compression  of 
lung,  or  pulmonary  tuberculosis.  An  excellent  opportunity  is  afforded 
for  the  study  of  vesicular,  bronchial,  and  bronchovesicular  respirations 
by  daily  examinations  of  a  case  of  fibrinous  pneumonia.  During  the 
first  few  hours  the  respiration  may  remain  vesicular  in  character.  This  is 
followed  by  bronchovesicular  breathing  for  a  short  period,  and  in  turn 
succeeded  by  the  bronchial  type,  or  in  rare  instances,  by  an  entire  absence 
of  respiratory  sounds.  When  resolution  ha.s  become  thoroughly  estab- 
lished, the  respiration  grailually  changes  from  the  lu-onchial  to  the 
bronchovesicular  variety,  the  former  becoming  less  pronounced  with 
each  succeeding  day,  and  the  latter  more  clearly  apparent.  As  conva- 
lescence continues  the  tubular  quality  is  less  easily  recognized,  the  pitch 
being  lower  both  in  inspiration  and  in  expiration. 

Cavernous  Breathing. — This  form  of  breathing  is  described  by  many 
as  a  modification  of  bronchial  respiration,  and  is  pronounced  by  some 
to  be  identical  with  amphoric  breathing.  There  does  not  seem  to  be  any 
valid  reason  for  classifying  the  cavernous  with  the  amphoric,  nor  for 
regarding  it  as  one  of  the  varieties  of  bronchial  breathing.  Not  only  are 
the  pathologic  conditions  responsible  for  the  production  of  the  bronchial 
and  the  cavernous  varieties  distinctly  dissimilar,  but  the  characteristics 
of  the  two  tjq^es  of  respiration,  although  sometimes  difficult  of  clear 
discrimination  by  the  beginner,  are  sufficiently  unlike  to  avoid  erroneous 
conclusions  by  the  practised  observer.  While  there  is  a  certain  degree 
of  similarity  as  to  the  physical  conditions  pi'0(hi<iim  (he  cavernous  and 
amphoric  forms,  there  is  at  the  .same  time  siiliiciciit  ilifference  in  the 
dynamics  of  the  sounds  to  create  distinctive  cluiractcii.stics. 

Cavernous  respiration  suggests  the  presence  of  a  pulmonary  cavity, 
but  this  physical  sign  is  not  always  elicited  when  there  is  excavation. 
Generally  speaking,  the  cavity  must  be  of  fairly  large  size  and  situated 
comparatively  near  the  surface  of  the  lung  in  order  to  permit  the 
recognition  of  cavei'nous  respiration.  It  is  conceded  that,  for  the  ready 
detection  of  a  pulmonary  cavity  by  mea-ns  of  auscultation,  its  long 
dianiptcr  must  :iiipro\im;itc'  six  ccntinictcrs  in  Icuiith.  If  the  c;ivit\-  is 
centnilly  located  and  sun-oumlcd  by  ci.iisolKhitcd  lung,  the  i-cspinifoiy 
sounds  may  siiuuhite  to  some  extent  bronchial  breathing,  tlie  cavernous 
signs  being  obscured  by  the  intervening  consolidation.  The  phy.sical 
conditions  requisite  for  the  production  of  cavernous  breathing  are  the 
entrance  of  air  into  the  pulmonary  cavity  with  each  inspiration,  and 
its  exit  upon  expiration.  This  predicates  the  fart  that  the  walls  of  the 
cavity  must  be  flaccid  and  yielcling,  and  that  communication  be  estab- 
lished with  an  unobstructed  bronchus.  The  bronchial  tube  leading  to  a 
cavity  frequently  becomes  occluded  by  a  thick  plug  of  mucus,  in  which 
event  the  characteristic  sign  is  incapable  of  recognition.  This  accounts 
for  the  alternating  presence  or  absence  of  cavernous  respiration  over 
the  site  of  a  cavity  at  different  periods.  In  siispected  cases,  when  the 
.signs  are  not  perfectly  clear  as  to  the  existence  of  pulmonary  exca- 
vation, the  patient  should  be  instructed  to  cough  in  an  effort  to  dislodge 
any  obstructing  plug.     It  is  often  unwise,  from  a  single  examination,  to 


208  PHYSICAL    SIGNS 

deny  positively  the  existence  of  cavity.  Not  infrequentl}-  I  have  been 
unable  to  demonstrate  the  auscultatory  signs  of  a  pulmonary  cavity, 
the  existence  of  which  had  been  shown  upon  a  previous  examination. 

In  cavernous  breathing  the  intensity  is  variable  and  the  quality 
blowing  both  during  inspiration  and  expiration,  being  similar  to  that 
of  expiration  during  vesicular  breathing.  The  pitch  is  low  during 
both  respiratory  acts,  but  is  lower  in  expiration,  and  the  duration  is 
longer.  The  intensity  is  not  an  important  consideration,  the  essential 
features  being  the  invariable  blowing  quality,  the  lower  pitch,  and 
the  longer  duration  of  expiration.  Cavernous  breathing  resembles 
the  bronchial  type  in  no  respect  save  that  the  expiration  is  prolonged 
in  each,  but  the  higher  pitch  and  tubular  quality  of  the  latter  are  dis- 
tinguishing features.  Cavernous  breathing  is  similar  to  vesicular  respi- 
ration in  the  low  pitch  of  inspiration  and  the  still  lower  of  expiration. 
The  blowing  quality  of  the  latter,  however,  is  not  present  in  vesicular 
inspiration.  In  the  cavernous  type  the  expiration  is  of  much  longer 
duration.  A  pulmonary  cavity  may  exist  in  close  proximity  either  to 
a  consolidated  area  or  to  normal  lung  tissue.  This  may  give  rise  to  the 
possibility  of  such  modifications  of  the  pure  cavernous  type  as  to  suggest 
a  separate  designation.  The  term  "  metamorphosing  respiration"  has 
been  applied  to  an  admixtvire  of  the  ca\'ernous  with  the  vesicular,  or 
the  cavernous  with  the  bronchial,  or  the  vesicular  with  the  bronchial 
types  of  breathing,  but  this  .seems  to  be  an  unfortunate  misnomer  as 
applied  to  these  conchtions.  Metamorphosing  respiration  should  be 
limited  to  the  description  of  cases  in  which  there  is  recognized  an  inspi- 
ration of  one  type  and  an  expiration  conforniiim  ilistinctly  to  another. 
It  is  well,  therefore,  to  designate  cases  in  which  the  (^nernous  variety 
is  combined  more  or  less  with  the  bronchial  a.s  "  bronchocavernous" 
respiration,  and  those  in  which  the  cavernous  and  vesicular  are  blended 
as  the  "vesiculocavernous"  breathing,  in  the  same  way  as  was  derived 
the  term  "  bronchovesicular." 

Bronchocavernous  breathing  may  occasionally  be  recognized  when 
the  cavity  is  situated  in  close  proximity  to  an  area  of  indurated  lung. 
The  vesiculocavernous  breathing  is  sometimes  olitainefl,  though  less 
often,  when  the  cavity  is  surrounded  by  normal  piilninnary  tissue.  In 
rare  instances  it  is  possible  for  genuine  caAfiiums  ics])iration  to  be 
heard  in  cases  of  pneumothorax,  but  usually  the  anatomic  conditions 
materially  mocUfy  the  sound  and  give  rise  to  the  physical  sign  called 
amphoric  respiration. 

Amphoric  Respiration. — For  the  production  of  this  type  of  breath- 
ing it  is  essential  that  there  exist  a  cavity  of  considerable  size  in  the 
lung,  or  an  open  pneumothorax,  the  presence  of  firm,  non-collapsing 
walls,  and  communication  with  an  open  bronchial  tube.  The  character- 
istics of  amphoric  breathing  are  in  many  resjjects  similar  to  those  of 
cavernous  respiration,  the  only  point  of  difference  being  the  musical 
quality,  which  is  the  distinguishing  feature  of  the  former.  This  peculiar 
intonation  is  produced  by  the  vibrations  in  a  resonant  cavity,  and  may 
be  imitated  by  blowing  over  the  mouth  of  an  empty  Ijottle.  A  fairly 
good  idea  of  the  musical  quality  may  also  be  obtained  by  blowing 
gently  with  the  lips  partly  closed  in  the  act  of  giving  a  low  whistle,  or 
by  pronouncing  "who"  with  the  whispered  voice. 

M ctamorphoxing  Respiration. — As  has  been  stated,  this  term  can  be 
propei'ly  applied  only  to  cases  in  which  the  inspiration  of  one  type  of 


AUSCULTATION  209 

breathing  is  combined  with  an  expiration  conforming  to  an  entirely 
different  variety.  A  vesicular  inspiration  is  sometimes  found  in  con- 
j  miction  with  a  bronchial  expiration,  a  cavernous  inspiration  with  a 
bronchial  expiration,  and  a  vesicular  inspiration  with  a  cavernous 
expiration.  When  auscultation  is  practised  over  normal  lung  in  close 
proximity  to  a  consolidatetl  area,  a  vesicular  inspiration  may  be  com- 
bined with  a  bronchial  expiration.  By  virtue  of  its  greatly  increased 
intensity  the  expiratory  sound  is  conveyed  to  the  ear  from  the  area  of 
consolidation.  Auscultation  over  normal  lung  adjacent  to  a  pulmonary 
cavity  in  the  same  way  may  disclose  an  inspiration  of  vesicular  type 
and  an  e.xpiration  cavernous  in  character,  because  of  the  relative 
increase  in  length  and  the  greater  intensity  of  the  expiratory  note  in 
cavernous  breathing.  In  like  manner  auscultation  over  a  cavity 
in  the  midst  of  consolidated  Imm  may  icNcal  (lie  blowing  quality  of 
cavernous  breathing  upon  inspirai  ion.  and  a  tulmlar  quality  transmitted 
from  the  adjoining  consolidation  duriui;  expiration.  Another  descrip- 
tion of  metamorphosing  breathing  is  sometimes  applied  to  the  change 
following  the  dislodgment  of  an  obstructing  plug  of  mucus,  thereby 
affording  opportunity  for  the  recognition  of  sounds  emanating  from  a 
cavity  into  which  the  air  tliil  not  previously  enter. 

Changes  in  Duration. — From  what  has  been  stated  with  reference 
to  changes  in  intensity,  pitch,  and  quality,  it  is  apparent  that  these 
modifications  of  the  ikhim.iI  bical  h-Miumls  cdnstilute  pliy^ical  e\idences 
of  great  importance  in  (lie  ilia.mmsis  <\\  disi'ase.  statements  li.aN'e  also 
been  made  concernin.ii  the  coixi.stent  variations  in  the  duration  ui  respira- 
tory sounds.  Differences  in  duration  cannot  be  regarded  as  distinct 
physical  signs,  but  are  invariably  associated  with  changes  in  pitch  and 
quality. 

Shortening  of  Inspiration. — This  occurs  in  two  distinct  types  of 
bi'eathing,  which  have  been  described.  In  broncliial  respiiation  the 
shoi'tening  occurs  at  the  end  of  the  inspiratory  act,  but  in  t  nqihysema- 
tous  lireathinK  at  the  beginning.  In  the  former  the  pitch  is  high  and 
the  (piality  lironchial;  in  the  latter  the  pitch  is  low  and  the  quality 
faintly  vesicular.  If  the  inspiration  is  shortened,  a  detennination  of 
the  type  of  respiration  is  snmetimes  ]ic)ssilile  fi-om  a  study  of  the  pitch 
and  quality  of  the  iusjuratoiy  sciuud  alone.  \alual>l(>  confirmatory 
evidence  is  afforded  by  study  of  the  expiration,  wliicli  in  bronchial 
breathing  is  still  higher  pitched  and  of  tubulai-  (|uality,  and  in  the 
emphysematous  variety  of  lower  pitcli  and  \-esic\il,ii-  in  ([uality. 

Prolongation  of  the  Expirntinn . — 'i'liis  (iccairs  in  lour  (y])es  of  breath- 
ing— the  bronchial,  eniplnseinatoiis,  ca\iTii(Mis,  .and  amphoric.  A  recog- 
nition of  the  particular  \aiiet\'  ol'  icspirat  inn  i-  nliiaiiieil  liy  reference 
to  pitch  and  quality.  In  lirouclnaj  lavadiing  the  prolonged  expiration 
is  high  pitched  and  tubular  in  (|uality:  in  the  emphysematous  form  it 
is  low  pitched  and  faintly  vesicular;  in  the  cavernous  type  it  is  low 
pitched  and  blowing,  while  in  the  am|ilinric  it  is  low  pitched  and  mu.sical. 
A  fairly  accurate  estimate  of  the  \:iiiet\-  ol  lespiration  in  the  presence 
of  prolonged  expiration  can  be  made  iVom  the  jiiidi  and  <|uality  of  the 
expiration  itself,  without  reference  to  (lie  inspiration,  in  dotibtful 
cases  it  is  of  vast  service  to  note  the  dillerence  of  pitch  in  expiration 
and  inspiration,  the  higher  pitch  with  the  iiil)iil,ir  qualit\-  oi  ex)iiration 
suggesting  lironchial  breathing,  and  the  relati\e  lowncss  of  pitch  with 
blowing  quality  denoting  cavernous  respiration. 


210  PHYSICAL    SIGNS 

Change  in  the  Rhythm  of  Respiration. — In  addition  to  changes 
in  duration  there  is  occasionally  observed  a  variation  of  rhythm.  This 
form  of  interrupted  breathing  is  sometimes  called  "cog-wheel  respira- 
tion," having  a  jerky,  irregular  inspiration.  The  impression  is  given 
that  there  is  some  mechanic  hindrance  to  the  free  entrance  of  air  to 
the  alveoli,  and  during  inspiration  an  effort  is  apparently  made  to 
overcome  an  obstruction  to  the  passage  of  air  through  the  finer  tubes, 
Formerh-  more  importance  was  attached  to  the  presence  of  this  physical 
sign  than  at  present.  Interrupted  breathing  may  be  recognized  as 
either  general  or  local.  If  general,  but  little  significance  need  be 
attached  to  its  recognition.  In  such  cases  it  is  due  to  imperfect  acts 
of  breathing,  either  from  pain,  as  in  pleurisy  and  intercostal  neuralgia, 
or  occurs  in  nervous  people  and  in  those  especially  fatigued.  It  is 
quite  frequently  observed  in  women  who  are  more  or  less  nervous  and 
embarrassed  at  the  time  of  examination. 

When  obtained  over  a  localized  area,  it  may  be  regarded  as  evidence 
of  some  obstruction  in  the  finer  bronchi,  due,  no  doubt,  to  the  thickened 
mucous  membrane  or  to  valve-like  occlusion  of  the  tubes  from  masses  of 
secretion.  This  explains  its  not  infrequent  presence  in  cases  of  incipient 
apical  tuberculosis  with  catarrhal  bronchiolitis. 

Rales. — Rales  are  distinguished  from  the  foregoing  modifications 
of  normal  auscultatory  sounds  in  being  entirely  different  from  those 
produced  in  health.  They  are  much  easier  of  detection  than  the  modifi- 
cations of  normal  sounds,  yet  their  presence  is  very  frequently  over- 
looked by  reason  of  faulty  technic.  This  is  shown  in  failure  to  examine 
the  entire  chest  and  in  neglect  to  utilize  cough  immedlatelii  preceding  a 
sharp  inspiration.  While  rales  are  often  recognized  upon  easy  respira- 
tion, those  which  are  of  the  utmost  importance  in  diagnosis  are  elicited 
in  many  instances  only  by  the  employment  of  cough.  This  is  particularly 
true  of  early  apical  tuberculosis  before  the  development  of  extensive 
tissue  change.  In  innumerable  cases  a  sufficiently  positive  diagnosis  of 
pulmonary  tuberculosis  can  be  made  by  the  detection  of  unilateral  rales 
before  the  appearance  of  other  ph3'sicai  .signs  and  prior  to  expectoration. 

There  exists  an  unfortunate  laxity  of  method  in  the  classification  of 
rales.  This  entails  exceeding  confusion  antl  doubt  in  the  minds  of  students 
as  to  the  significance  of  various  rales  and  their  method  of  origin.  Some 
authors  classify  rales  according  to  dryness  or  moistiu-e;  others  point 
out  distinctive  cUfferences  in  their  qualitj-,  pitch,  or  inten.sity,  or  make 
use  of  purely  descriptive  terms.  The  best  plan  seems  to  be  a  classifica- 
tion according  to  anatomic  location,  with  qualifying  descriptions  with 
reference  to  moisture  and  dryness,  and  a  final  analysis  according  to  size, 
quality,  and  time.  I  am  well  aware  of  the  deficiencies  and  limitations 
of  any  .system  of  nomenclature,  and  can  claim  no  special  originality 
for  the  method  to  be  presented.  It  is  the  one,  however,  that,  in  teach- 
ing, I  have  followed  for  many  years  and  have  found  to  be  more  satis- 
factory than  any  other  on  the  score  of  simplicity. 

Rales  may  be  divided  according  to  their  anatomic  location  as  follows: 
the  tracheal,  bronchial,  vesicular,  cavernous,  and  pleural.  These  are 
.subject  to  further  clas.sification  according  to  moisture  or  dryness,  size, 
quality,  and  time. 

Tracheal  Rales. — These  maj'  be  either  moist  or  dry.  Moist  tracheal 
rales  are  produced  by  the  presence  of  liquid  in  the  trachea  through 
which  the  air  passes  with  each  respiratory  act.     They  are  heard  both 


AUSCULTATION  211 

on  inspiration  and  on  expiration,  and  occur  more  frequently  in  the 
moribund  state,  at  which  time  they  constitute  what  is  commonly  called 
the  death-rattle.  They  are  also  found  in  states?  of  coma  in  which  the 
sensibility  of  the  mucous  membrane  is  so  benumbed  as  to  preclude  an 
effort  toward  expulsion.  Moist  tracheal  rales,  both  in  children  and 
adults,  are  sometimes  heard  even  at  a  distance  from  the  patient.  This 
is  particularly  true  in  late  stages  of  pneumonia,  when  the  secretions 
accumulate  in  the  trachea  and  give  rise  to  loud  bubbling  sounds.  It  is 
not  true  that  the  existence  of  these  rales  necessarily  presupposes  the 
death  of  the  individual.  Prompt  emesis  in  children  very  often  suffices 
to  remove  the  liquid  in  the  bronchial  tract  to  such  an  extent  as  to 
cause  for  a  time  the  entire  disappearance  of  tracheal  rales.  Recovery 
is  not  impossible  even  in  adults,  despite  the  ominous  import  of  the 
death-rattle.  In  croupous  pneumonia  remarkable  results  are  sometimes 
obtained  even  in  the  very  midst  of  impending  death  through  recourse 
to  prompt  and  thorough  venesection.  It  seems  little  short  of  miracu- 
lous to  observe  the  wonderful  improvement  which  immediately  ensues 
in  some  cases  following  relief  to  the  right  heart  and  engorged  pulmonary 
circulation. 

The  Dry  Tracheal  Rale. — This  variety  is  not  produced  like  the 
preceding,  by  the  passage  of  air  through  liquid,  but  its  origin  is  incident 
to  conditions  closing  to  a  variable  degree  the  lumen  of  the  trachea  or 
producing  some  deviation  of  contour.  Dry  rales  emanating  from  the 
upper  respiratory  passages  may  result  from  affections  of  the  glottis,  as 
spasm  or  edema,  and  from  the  presence  of  an  exudative  process,  as  in 
diphtheria.  They  may  also  be  produced  by  large  masses  of  tenacious 
secretion  adhering  to  the  wall  of  the  tube  over  which  the  air  passes,  the 
sounds  having  a  more  or  less  distinctive  character.  The  existence  of  a 
tumor  encroaching  upon  the  lumen  of  the  trachea  for  the  same  reason 
cau.ses  this  type  of  rales.  It  is  remarkable  how  an  extremely  small  new- 
growth  within  the  interior  of  the  trachea  may  cause  these  adventitious 
sounds. 

The  dry  rale  is  entirely  devoid  of  the  bubbling  character  of  the 
moist  variety,  and  may  be  described  as  whistling,  squeaking,  wheezing, 
or  stridulous. 

Moist  Bronchial  Rales. — These  are  produced  by  the  passage  of  air 
through  liquid  in  the  bronchial  tubes,  and  may  be  heard  l^oth  in  inspira- 
tion and  in  expiration.  Appreciable  differences  are  recognized  in  size 
according  as  the  rale  originates  from  a  large,  medium-sized,  or  small 
tube.  The  chief  distinguishing  (h.-iractcristics  of  these  rales  are  their 
bubbling  character,  their  ine<iualit\-  (i\cr  a  given  area,  and  the  time 
of  their  occurrence,  during  both  inspiiatidii  and  expiration.  They  are 
sometimes  inconstant.  Differences  as  to  pitch  and  intensity  are  not  of 
special  importance.  When  occurring  without  pronounced  pathologic 
change  in  the  pulmonary  tissues,  the  intensity  is  not  a  noticeable  feature; 
there  is  no  elevation  of  pifrh  ami  no  approriation  of  quality  other  than 
as  relates  to  thcii-  biilililini;;  chai'arlcr.  When  recognized,  however,  in 
the  presence  of  cunsdlidatiMl  lun;;.  the  pitch  is  correspondingly  elevated, 
the  intensity  increased,  and  the  qualit\-  somctimos  liiming  or  explo.^ive. 
On  account  of  these  variations  in  quality,  pitcli,  ami  intensity,  according 
to  the  presence  or  absence  of  consolidation,  some  wiitcis  have  described 
the  moist  bronchial  rales  occurring  in  ndrinal  limg  tissue  as  "mucous" 
or  "  non-consonating"  rales,  and  those  heard  in  the  midst  of  well-marked 


212  PHYSICAL    SIGNS 

consolidation  as  "resonant"  or  "consonating"  rales.  The  specific 
characters  of  rales,  with  reference  to  pitch,  qualiti/,  and  intensity,  do  not 
constitute  practical  data  for  the  diagnosis  of  consolidated  lung.  It  appears 
unnecessary  to  suggest  differences  in  the  qualit\'  and  pitch  of  rales  as  a 
means  of  diagnosing  consolidated  areas.  Such  recoi;nition  is  much  more 
simple  and  accurate  by  means  of  percussion  and  by  modifications  of  the 
normal  breath-sounds.  The  term  "mucous  rales"  should  be  avoided, 
as  often  the  presence  of  mucus  does  not  result  in  the  production  of  moist 
bubbling  rales,  inasmuch  as  the  secretion  is  too  consistent  to  permit  the 
passage  of  air.  These  rales  far  more  frequently  are  produced  by  pus, 
Ijlood,  or  serum  in  the  tubes  tlian  by  mucus.  It  is  to  be  regretted  also 
that  the  word  ".subcrepitant"  is  used  to  describe  "moist  rales  occurring 
in  the  very  finest  iDronchial  tubes."  The  derivation  of  this  descriptive 
term  is  founil  in  the  fancied  resemblance  of  exceedingly  fine  moist  bron- 
chial rales  to  tho.se  originating  in  the  r.ir-vesicles,  and  sometimes  called 
"crepitant."  The  two  varieties  are  alike  in  being  very  fine,  but  aside 
from  this  feature  the  points  of  difference  are  very  distinct.  The  vesicular 
rales  are  ch-y,  rather  than  moist,  non-bul:)l3ling  in  character,  equal  in 
size,  and  occur  for  the  most  part  at  a  certain  specified  time  during  the  act 
of  respiration.  The  use  of  the  word  "subcrepitant"  as  descriptive  of 
the  fine  moist  bronchial  rale  has  led  to  endless  confusion  among  clinicians. 
In  the  interests  of  exactitude  it  is  far  better  to  discontinue  the  employ- 
ment of  the  words  crepitant  and  subcrepitant.  to  limit  the  classification 
of  moist  bronchial  rales  to  the  coarse,  medium-sized,  and  fine,  and  to 
describe  rales  arising  from  the  air-vesicle  as  "vesicular."  The  latter 
may  be  further  qualified,  if  desired,  by  using  the  word  "  dry"  or  "  crack- 
ling." 

Moist  bronchial  rales  may  be  heard  in  the  midst  of  any  condition 
which  induces  the  presence  within  the  bronchial  tubes  of  homogeneous 
liquid  through  which  air  can  readily  pass.  In  acute  bronchitis  affecting 
chiefly  the  large  tubes  the.se  rales  are  frequently  absent  altogether, 
because  of  the  scanty  secretion.  In  acute  bronchitis  involving  the  finer 
tubes,  and  in  chronic  bronchitis  in  which  the  .secretion  is  more  purulent 
and  thin,  the  rales  are  plainly  recognized.  They  are  heard  in  edema  of 
tlie  lungs  as  a  result  of  the  pre.sence  of  serum  in  the  bronchioles.  These 
rales  are  also  heard  following  pulmonary  hemorrhage  with  the  presence 
of  free  blood  in  the  bronchi,  and  in  the  course  of  pneimionia  after 
resolution  has  fairly  begun.  A  most  important  condition  disclosed  by 
tlieir  presence  is  the  unilateral  catarrhal  bronchiolitis  incident  to  the 
early  stage  of  pulmonary  tuberculosis. 

Dry  Bronchial  Rales. — These  rales  are  essentially  dry  in  character, 
and  their  quality  more  or  less  musical.  They  may  be  likened  to 
whistling,  wheezing,  squeaking,  or  liissing  noises,  which  are  heard  both 
upon  inspiration  and  expiratidu.  and  usually  in  all  parts  of  the  chest. 
These  sounds  may  be  recognized  at  one  location,  only  to  cUsappear  and 
return  from  time  to  time  chiring  the  same  examination.  The  dry  bron- 
chial rale  is  the  only  one  concerning  which  differences  of  pitch  are  worthy 
of  special  note.  Sounds  originating  in  the  finer  tubes  are  of  higher 
pitch  and  are  called  sibilant.  These  are  more  or  less  shrill,  piping, 
hissing  sounds.  Those  arising  from  the  large-sized  tubes  are  lower 
pitched,  loud,  and  snoring  in  character,  and  are  described  as  sonorous. 
The  production  of  dry  bronchial  rales  is  chie  either  to  some  temporary 
occlusion  of  the  lumen  of  the  bronchial  tubes  or  to  a  constriction  of  the 


AUSCULTATION  213 

wall  from  spasm  of  the  muscular  fibers.  These  rales  are  sometimes 
present  in  the  course  of  bronchitis,  even  if  unassociated  with  much 
secretion.  The  most  typical  illustration  of  their  occurrence  is  found  in 
bronchial  asthma  and  chronic  influenza. 

The  Vesindar  Rale. — There  has  been  for  a  long  time  a  difference  of 
opinion  as  to  the  manner  of  production  of  this  rale,  and  in  recent  years 
as  to  the  specific  time  of  its  development.  Some  observers  have  been  led 
to  regard  the  rale  as  entirely  pleuritic  in  origin,  antl  it  is  quite  proliaUe 
that  this  is  sometimes  the  case.  To  determine,  however,  the  preci.se 
manner  of  its  production  is  not  so  important  as  to  ol:)tain  a  clear  under- 
standing of  its  characteristics.  All  conclusions  as  to  the  method  of 
derivation  are  more  or  less  matters  of  theory.  Personally,  I  am  some- 
what slow  to  renounce  the  assumption  that  this  rale  is  produced  at  the 
end  of  a  forcible  inspiration  by  the  separation  of  opposing  surfaces  of 
alveoli  which  were  previously  agglutinated  bj-  gelatinous  secretions. 
The  important  features  of  the  vesicular  rale  are  its  fineness,  its  inrariahic 
crackling  or  clicking  character,  its  (ijiiiilili/.  all  rales  being  identica],  and 
its  occurrence  at  the  very  etui  oj  iu^^pirdtion.  It  is  often  proclaimed  that 
this  rale  is  sometimes  semimoi.st  in  character,  and  that  it  may  lie  heard 
during  expiration  as  well  as  inspiration.  It  is  true  that  very  fine  "  semi- 
dry'  '  rales  of  a  clicking  character  are  occasionally  heard  with  expiration, 
as  well  as  with  inspiration,  but  these  mixed  soimds  should  not  be  desig- 
nated as  corresponding  to  the  pure  t\  pc  ol'  xc-inilai'  i-ale.  They  should 
be  styled  fine,  moist,  semimoist,  or  iiKlctcmiiniite  rales. 

The  vesicular  rale  has  long  lieeii  ivgartled  as  pathognomonic  of  a 
single  pathologic  condition,  viz.,  consolidation  of  lung  in  the  early  stages 
of  croupous  pneumonia.  At  this  time  it  is  often  called  the  crepitant 
rale,  in  contradistinction  to  the  so-called  returning  crepitant  rale  which 
is  recognized  in  the  beginning  of  resolution.  In  the  early  stage  of 
pneumonia  the  appellation  should  be  the  vesicular  rale,  and  in  the  stage 
of  resolution  the  fine  moist  bronchial  rale. 

It  is  not  well  td  rciiaid  jincumonia  as  the  only  condition  giving  rise 
to  the  production  of  the  \csicular  rale.  It  is  often  heard  in  the  lower 
lateral  region  and  at  the  posterior  bases  in  the  later  stages  of  typhoid 
feve]-,  when  the  patient  is  turned  to  the  side  or  supported  in  the  silting 
l)osition.  It  may  be  recognized  when  the  patient  has  been  confined  to 
the  bed  for  prolonged  periods  from  any  cause,  particularly  if  there  is 
deficient  respiration,  and  in  atelectasis  of  the  aged.  Rales  closely  resem- 
bling the  vesicular  are  heard  in  the  cour.se  of  incipient  pulmonary  tuber- 
culosis before  the  secretions  in  the  finer  bronchioles  are  sufficient  to 
induce  buttbling  sounds. 

The  Cavernous  Rdle. — This  is  produced  by  the  presence  of  liquid 
in  a  medium-sized  or  large  pulmonary  cavity,  through  which  the  air 
passes  u]ion  respiration  or  with  the  act  of  coughing.  It  is  distinctly 
gurgling  in  character,  and  is  usually  low  pitched,  although  if  the  cavity 
is  surrounded  by  indurated  lung  tissue,  its  pitch  may  bo  high.  The 
impression  is  given  to  the  examiner  of  large  l)ul)iilcs.  not  \inlike  those 
obtained  when  boiling  water  in  a  large  test-tube  (ir  small  flask. 

The  Pleural  Rale. — The  pleur.al  rales  may  I  jc  dixidcd  into  those  having 
their  origin  upon  the  surface  of  the  ojiiKising  layers  of  pleura  and  those 
produced  by  the  presence  of  liquid  witliiii  the  jijeural  cavity. 

A  considerable  variety  of  descriptive  terms  ai'e  ascriljed  to  the  former, 
which  is  accounted  for  by  the  diversity  of  existing  pathologic  conditions. 


214  PHYSICAL    SIGNS 

If  the  normal  amount  of  serum  in  the  pleural  cavity  sufficient  to  permit 
the  surfaces  of  the  pleura  to  glide  noiselessly  over  each  other  is  dimin- 
ished to  a  material  extent,  there  results  a  slight  grazing  or  rubbing 
sound,  as  a  result  of  the  mere  dryness  of  the  pleural  surface. 

If  the  exudative  process  is  of  a  plastic  or  mucilaginous  nature,  there 
may  be  produced  a  craclding  sound  as  the  opposing  surfaces  are  approxi- 
mated. 

If  the  exudation  is  of  a  firm,  rough,  shaggy,  and  fibrinous  nature, 
the  sounds  are  correspondingly  modified,  and  in  some  instances  are  of 
a  leathery  or  squeaking  character. 

Generally  speaking,  pleural  friction  rales  may  be  said  to  merge  from 
a  faint,  scarcely  perceptible,  grazing  sound  to  a  creaking,  crackling,  or 
leathery  rub.  The  friction-rub  may  be  imitated  by  moving  the  finger 
of  one  hand  against  the  palm  of  the  other  held  close  to  the  ear.  Pressure 
of  the  stethoscope  intensifies  the  sound,  which  appears  to  come  from 
directly  under  the  bell  of  the  instrument. 

Pleural  friction-sounds  may  be  heard  in  the  absence  of  any  pleuritic 
pain.  They  are  usually  recognized  in  the  lower  portion  of  the  axilla, 
and  are  more  or  less  interrupted,  occurring  principally  during  inspiration 
and  cough.  They  may  be  heard  in  dry  pleurisy  or  pneumonia,  and  not 
infrequently  at  the  apex  in  early  pulmonary  tuberculosis. 

Rales  arising  within  the  pleural  cavity  following  perforation  may  be 
divided  into  succussion  sounds  and  metallic  tinkling. 

Succiission  Sounds. — Succussion  rales  refer  to  loud,  splashy  sounds 
recognized  upon  shaking  the  patient  with  the  ear  held  to  the  chest. 
This  physical  sign  is  obtained  only  as  a  result  of  the  presence  of 
liquid  and  air  within  the  pleural  cavity.  It  is  not  found  in  pleurisy 
with  effusion  or  hydrothorax.  The  upper  level  of  the  liquid  always 
corresponds  to  a  horizontal  plane,  there  being  no  ciu'ved  line  of  dulness 
or  flatness,  as  in  the  case  of  pleural  effusions.  There  is  also  a  deviation 
of  the  upper  level  of  flatness,  corresponding  to  a  change  in  the  position 
of  the  patient,  which  is  not  true  to  an  equal  extent  in  pleurisy  with 
effu.sion. 

Metallic  Tinkling. — This  physical  sign  may  be  elicited  in  pneumo- 
thorax, and  exceptionally  in  large  pulmonary  cavities  partly  filled  with 
liquid  and  having  a  free  opening  into  a  bronchial  tube.  Metallic  tink- 
ling is  by  no  means  constant,  even  in  pneumothorax.  For  its  production 
it  is  necessary  that  there  should  be  an  open  communication  with  a  bron- 
chus above  the  level  of  the  liquid.  It  consists  of  a  series  of  high-pitched 
silvery  notes  which  may  arise  during  respiration,  coughing,  or  speaking. 
The  sounds  suggest  drops  of  water  gently  falling  upon  the  surface 
of  liquid  contained  within  a  resonant  cavity.  They  are  not  unlike 
the  tinkle  produced  by  tapping  lightly  the  highest  bars  of  a  xylophone. 
There  is  also  a  resemblance  to  the  striking  of  tiny  bells  at  a  distance. 

Iiuhierminntc  Rales. — It  is  not  practicable  to  devote  especial  atten- 
tion to  the  study  of  these  rales.  For  the  sake  of  (•on\'enience  it  is  suffi- 
cient to  include  under  this  heading  all  sounds  not  distinctly  characteristic 
of  the  rales  whicli  have  been  described.  They  possess  hut  very  little 
actual  importance  to  the  student,  and  their  detailed  ilescription  would 
only  result  in  unnecessary  confusion. 


AUSCULTATION  215 


MODIFICATIONS  OF  THE  NORMAL  SPOKEN  AND  WHISPERED  VOICE 

IN  DISEASE 

The  Spoken  Voice. — This  sound  in  health,  or  the  so-called  normal 
vocal  resonance,  has  been  described  as  a  diffused,  low-pitched  vibration, 
lackin.n  the  concentration,  shock,  high  pitch,  and  nearness  of  the  souncl 
heard  when  listening  to  the  voice  over  the  trachea  or  larynx.  In  the 
midst  of  various  pathologic  conditions  the  vocal  resonance  is  subject 
to  a  variety  of  changes.  Just  as  the  modifications  of  the  normal  respira- 
tory sounds  were  studied  with  reference  to  changes  in  intensity,  pitch, 
and  quality,  so  the  modifications  of  the  spoken  voice  should  be  analyzed 
in  accordance  with  the  same  method. 

Changes  in  Intensity. — This  includes  entire  suppression  or  diminution 
and  increa.sed  intensity  of  vocal  resonance. 

Suppression  or  Diminution  of  Vocal  Resonance. — This  may  result 
from  the  interposition  of  a  layer  of  liquid  between  the  lung  and  the 
chest-wall,  as  in  pleural  effusion,  the  presence  of  a  large  body  of  air  in 
the  pleural  cavity,  as  in  pneumothorax,  edema  of  the  lung,  a  large  cavity 
filled  with  liquid,  obstruction  of  a  primary  bronchus  from  pressure  of 
aneurysm  or  enlarged  mediastinal  gland,  and  rarely  complete  consoli- 
dation of  lung  in  croupous  pneumonia. 

In  pleurisy  with  effusion,  hydrothorax,  or  pneumohydrothorax  the 
diminished  intensity  of  the  vocal  resonance  constitutes  a  physical  sign 
of  great  importance.  In  these  conditions  and  in  simple  pneumothorax 
the  voice-sounds  are  invariably  transmitted  with  but  feeble  intensity. 
In  pneumonia  the  vocal  resonance  is  usually  perceptibly  increased,  but 
the  reverse  may  be  true  in  some  instances.  In  severe  cases  of  pulmo- 
nary edema  the  intensity  is  lessened  by  the  presence  of  serum  in  the  air- 
vesicles  and  in  the  interstitial  tissue  of  the  lung.  When  the  diminished 
voice-sounds  are  occasioned  by  the  existence  of  a  cavity  filled  with 
liquid,  the  signs  are  circumscribed  in  area.  The  enfeeblement  of  vocal 
resonance  from  compression  of  a  Ijronchial  tube  from  any  cause  affords 
a  suggestion  that  the  sounds  are  transmitted  to  the  ear  of  the  examiner 
through  the  medium  of  the  column  of  air  contained  within  the  bronchial 
tubes,  rather  than  through  the  bronchial  or  pulmonary  tissues.  Many 
times  I  have  noted  complete  absence  of  vocal  resonance  throughout  an 
entire  side,  as  a  result  of  aneurysm  or  an  enlarged  mediastinal  gland. 

Increased  Vocal  Resonance. — In  calling  attention  to  the  increased 
intensity  of  the  normal  voice-sounds  observed  in  certain  morbid  states, 
it  is  desired  to  emphasize  the  fact  that  no  reference  is  made  to  accom- 
panying changes  in  pitch  or  quality.  In  this  connection  the  increased 
intensity  of  the  sound  may  be  due  either  to  partial  consolidation  of  the 
lung  or  to  the  presence  of  a  pulmonary  cavity. 

It  may  be  heard  over  lung  partially  consolidated  from  any  cause, 
as  pneumonia,  pulmonary  tuberculosis,  or  compi'ession.  In  beginning 
consolidation  the  vocal  resonance  often  remains  low  pitched  and  more 
or  less  diffused  or  distant,  although  increased  in  intensity.  As  the  con- 
solidation increases,  definite  changes  in  pitch  and  quality  take  place, 
irrespective  of  the  intensity,  which  may  even  become  diminished. 

Increased  vocal  resonance  may  be  heard  over  pulmonary  cavities, 
particularly  if  superficial  and  opening  into  a  bronchial  tube.  If  the 
cavity  is  situated  in  the  midst  of  comparatively  normal  lung  tissue, 
the  pitch  is  low  and  the  only  remarkable  deviation  from  the    normal 


216  PHYSICAL    SIGNS 

is  the  increased  intensity.  If  surrounded  by  consolidated  lung,  the 
pitch  becomes  correspondingly  ele^•ated.  the  sound  more  concentrated, 
associated  with  greater  shock,  and  apparently  nearer  to  the  ear.  In 
the  majority  of  instances  auscultation  of  the  spoken  voice  over  the  site 
of  pulmonary  cavities  discloses  other  changes  than  mere  increase  of 
intensity,  which  characteristics  will  be  described  presently. 

Changes  in  Pitch  and  Quality. — These  include  bronchophony," 
egoj:)hony,  pectoriloquy,  cavernous  voice,  and  amphoric  voice. 

Bronchophony. — The  characteristics  of  bronchophony  are  identical 
with  the  normal  voice-sounds  heard  during  auscultation  over  the  trachea 
or  larynx.  They  consist  of  high  pitch,  nearness,  concentration,  vibra- 
tion, or  shock.  The  impression  of  nearness  to  the  ear  or  concentration 
is  usually  quite  vivid,  in  contrast  to  the  diffusion  and  distance  received 
when  listening  over  normal  lung.  The  shock  conveyed  to  the  ear  of  the 
examiner  is  distinctly  disagreeable,  although  the  intensity  is  not  always 
increased.  The  latter  does  not  enter  into  the  distinctive  features  of 
bronchophony.  This  sign  is  often  heard  over  consolidated  lung,  and  has 
the  same  significance  as  bronchial  breathing,  although  bronchophony 
ma>-  be  recognized  with  a  lesser  degree  of  consolidation  than  necessary 
for  tlie  production  of  bronchial  breathing. 

Egophony. — Egophony  is  a  modification  of  bronchophony,  produced 
by  the  presence  of  liquid  intervening  between  compressed  lung  and  the 
chest-wall,  as  in  pleural  effusion.  Two  important  characteristics  of 
egophony  are  its  high  pitch  and  its  concentration.  The  sensation  of 
concentration  is  opposecl  to  the  diffuseness  of  normal  vocal  resonance, 
but  the  nearness  of  bronchophony  is  replaced  by  an  impression  of 
distance.  There  is  superadded  to  these  features  a  certain  tremulous- 
ness  which  has  been  described  as  analogous  to  the  bleating  of  the  goat, 
hence  the  derivation  of  the  name.  It  is  not  always  heard  in  cases  of 
pleural  effusion,  but  is  often  detected  near  the  level  of  the  liquid  when 
the  effusion  is  of  but  moderate  size.  It  is  sometimes  present  over  con- 
solidated lung,  but  does  not  con.stitute  a  sign  of  special  moment. 

Pectoriloquy. — This  refers  to  the  audible  transmission  to  the  examiner 
not  only  of  the  sound  of  the  spoken  voice,  but  also  the  words  themselves. 
This  sign  may  be  elicited  in  the  presence  of  con.solidated  lung,  pulmo- 
nary cavities,  and  occasionally  open  pneumothorax.  Pectoriloquy  does 
not  involve  necessary  changes  in  intensity,  pitch,  or  quality,  but  usually 
partakes  more  or  less  of  the  bronchophonic  characteristics  peculiar  to  con- 
solidated lung,  and  sometimes  suggests  the  cavernous  voice. 

The  Cavernous  Voice. — This  is  not  an  important  sign,  and  is  worthy  of 
only  the  merest  mention.  The  cavernous  voice  is  heard  chiefly  when 
pulmonary  excavation  has  taken  place  in  the  midst  of  indurated  lung 
tissue.  The  sound  is  more  or  less  intensified,  with  a  certain  admixture  of 
the  bronchophonic  element.  Wlrile  it  does  not  pos.sess  the  distinct 
high-pitched  shock  of  bronchophony,  it  is  materially  different  from 
the  simple  increase  of  intensity  heard  over  cavities  in  the  midst  of  normal 
lung  tissue. 

The  Amphoric  Voice. — The  essential  characteristic  of  this  physical 
sign  consists  of  its  musical  intonation,  which  is  dependent  upon  the 
presence  of  a  body  of  air  within  a  resonant  cavity.  It  is  heard  more 
frequenth'  in  pneumothorax  than  in  anj'  other  condition,  although  it 
may  be  recognized  occasionally  over  large  pulmonary  cavities  with 
unvielding  walls. 


AUSCULTATION  217 

The  Whispered  Voice. — The  normal  whispered  voice  has  been 
ilescribed  as  exceedingly  faint,  soft,  and  low  pitched,  corresponding  to 
the  sound  of  expiration  in  vesicular  respiration.  It  seems  unnecessary 
to  enumerate  in  detail  the  modifications  of  the  normal  whispered  reso- 
nance which  take  place  in  disease,  in  view  of  the  fact  that  the  changes 
are  almost  identical  with  those  described  with  reference  to  the  spoken 
voice.  It  is  sufficient  to  repeat  briefly  that  the  whispered  resonance 
may  be  studied  with  regard  to  changes  of  intensity,  pitch,  and  cjuality. 
The  intensity  may  be  diminished  or  absent  from  the  same  causes  which 
produce  enfeeblement  of  the  sound  of  the  spoken  voice,  although  the 
whispered  resonance  may  be  entii'ely  absent  when  the  spoken  voice  is 
readily  appreciable.  Even  in  health  it  is  so  feeble  as  scarcely  to  be 
heard,  save  over  the  regions  of  the  primary  bronchi. 

The  intensity  may  be  increased  from  partial  consolidation  of  lung 
or  the  presence  of  a  pulmonary  cavity.  When  due  to  slight  pulmonary 
consolidation,  not  only  is  the  intensity  increased,  but  the  pitch  is  more 
or  less  elevated  and  the  quality  slightly  bronchial.  The  change  in  pitch 
and  quality  is  due  to  the  fact  that  the  whispered  voice  is  precisely  iden- 
tical with  the  sound  of  expiration,  save  for  the  increased  intensity.  This 
increased  transmission  of  the  whispered  voice  with  associated  elevation  of 
pitch  and  tubular  quality  constitutes  a  very  valuable  sign  in  the  exami- 
nation of  patients  who  are  too  feeble  to  breathe  as  desired,  or  who  are 
afflicted  with  aphonia. 

An  increased  intensity  of  the  whispered  voice  is  often  appreciable 
before  recognition  of  bronchial  or  bronchovesicular  respiration  is  possi- 
ble. When  this  is  due  to  the  presence  of  a  cavity  in  the  midst  of  com- 
paratively normal  lung  tissue,  the  intensity  is  noticeably  increased,  but 
the  pitch  remains  low  and  the  quality  slightly  blowing,  the  sound  being 
described  as  the  cavernous  whisper. 

The  high  pitch  and  tubular  quality  of  the  whispered  voice  over 
thoroughly  consolidated  lung  are  sometimes  described  as  the  increased 
bronchial  whisper,  or  whispering  bronchophony. 

Over  a  pulmonary  cavity  of  considerable  size,  surrounded  by  indu- 
rated pulmonary  tissue,  the  whispered  voice  partakes  to  a  certain  extent 
of  the  characteristics  of  whispering  bronchophony. 

Whispering  pectoriloquy  may  be  heard  over  the  site  of  a  pulmonary 
cavity,  especially  if  superficially  located,  and  also,  though  less  often, 
over  consolidated  lung.  The  whispered  resonance  may  assume  a  musical 
echo,  and  is  spoken  of  as  the  whispered  amphoric  echo.  Sometimes  an 
appreciation  of  a  distinctly  musical  intonation  can  be  obtained  more 
easily  with  the  whi.spered  resonance  than  with  the  spoken  voice. 


218  PHYSICAL    SIGXS 

SECTION    II 

Physical  Signs  of  Pulmonary  Tuberculosis 

chapter  xxxiii 
general  considerations 

There  exists  no  conventional  standard  of  physical  signs  common  to 
all  cases  of  pulmonary  tuberculosis.  The  extent  and  character  of  phy- 
sical evidences  are  so  varied  in  different  incUviduals  as  to  preclude  the 
conception  of  a  definite  type  or  combination  of  signs.  Irrespective  of 
the  subjective  symptoms,  the  former  may  be  so  slight  as  scarcely  to  be 
recognizable  upon  rigid  examination,  and,  on  the  other  hand,  so  numer- 
ous and  complex  as  to  represent  a  remarkable  variety  of  morbid  changes. 
Pulmonary  tuberculosis  with  its  complications  may  admit  of  every  pos- 
sible sign  referable  to  intrathoracic  disease  in  general.  Some  consump- 
tives, on  the  other  hand,  present  every  external  appearance  of  health 
and  vigor,  displaying  either  extensive  destructive  change  or  compara- 
tively insignificant  physical  signs. 

The  range  of  possibilities  as  to  what  may  be  observed  upon  inspection, 
palpation,  percussion,  and  auscultation  is  almost  infinite.  It  is  mani- 
festly impracticable  to  attempt  the  description  of  any  group  of  phj-sical 
signs,  or  even  of  a  single  manifestation,  which  may  l)e  accepted  to  be 
of  general  application  in  consumption.  Current  medical  literature  upon 
the  diagnosis  of  pulmonary  tuberculosis  is  replete  with  classic  descrip- 
tions of  the  various  physical  signs,  which  too  frequently  are  grouped 
without  expression  as  to  their  respective  frequency  or  importance.  Obvi- 
ousl}-,  an  arbitrary  classification  of  signs  without  regard  to  their  con- 
stancy or  significance  affords  no  proper  accentiuition  of  their  compara- 
tive value.  Failure  to  discriminate  regarding  their  relative  importance 
has  led  to  much  difficulty  and  delay  among  students  and  iir;Mtitioners 
in  establishing  an  early  diagnosis  of  the  disease.  Mall^  >ii:!i-^  i  >  >!nnionly 
regarded  as  characteristic  of  phthisis  are  singularly  iiK  iin~i,int  (u  devoid 
of  definite  interpretation,  while  others,  actually  pathognomonic  in  import, 
are  elicited  only  upon  correct  methods  of  examination.  It  is  essential, 
therefore,  in  portraying  the  physical  signs  of  pulmonarv  tuberculosis, 
to  depict  certain  features  with  especial  clearness  in  the  foreground,  in 
order  to  afford  a  proper  perspective.  Signs  of  frequent  occurrence  and 
conspicuous  significance  should  be  contrasted  prominently  with  those  of 
minor  importance  and  uncertain  interpretation. 

As  a  matter  of  fact,  the  physical  evidences  of  early  pulmonary  phthi- 
sis do  not  refer  essentially  to  slight  ileviations  from  the  normal  apical 
boundaries  upon  percussion,  nor  to  doubtful  modifications  of  the  respira- 
tory murmur.  Several  physical  signs  arising  from  a  slight  deposit  of  tuber- 
cle at  one  apex  have  been  described  by  writers  with  infinite  pains,  but 
their  practical  value  is  often  vastly  subordinate  to  that  of  other  objec- 
tive manifestations,  the  im])ortance  of  which  is  not  always  appreciated. 
It  should  be  remembered  that  in  very  incipient  phthisis  gross  patho- 
logic change  capable  of  detection  by  means  of  physical  examination  is 
comparatively  infrequent,  the  area  involved  being  of  such  minute  size 


EARLY    CASES  219 

and  depth  from  the  surface  as  to  preclude  recognition  even  by  the  most 
skilled  examiners.  Furthermore,  the  foci  of  infection  are  sometimes 
scattered  to  a  considerable  extent  and  separated  from  one  another  by- 
intervening  lung  tissue,  which  is  either  of  normal  character  or  the  sub- 
ject of  slight  degree.s  of  compensatory  emphysema,  rendering  still  more 
obscure  the  detection  of  finer  structural  change. 

In  applying  to  pulmonary  tuberculosis  the  general  principles  of 
physical  diagnosis  enumerated  in  the  preceding  section,  each  sign  will 
be  considered  separately,  but  an  effort  will  be  made  to  dwell  at  length 
only  upon  features  of  decided  practical  importance.  It  is  believed  that 
more  of  real  interest  and  value  will  accrue  to  general  practitioners  from 
a  review  of  the  more  common  factors  of  supreme  significance,  than 
from  the  perusal  of  pages  devoted  purely  to  a  recapitulation  of  the  ultra- 
refined  aspects  of  physical  diagnosis.  The  latter  are  of  exceptional 
occurrence,  of  cUfficult  recognition,  and  sometimes  of  doubtful  impoit. 
It  is  affirmed  with  cniphasis  that  failure  to  detect  the  evidences  of  pul- 
monary tuberculosis  i^  n<it  occa.sioned,  in  the  majority  of  instances, 
by  an  actual  paucitN-  dl'  phy.sical  signs,  nor  by  the  non-recognition  of 
obscure  shades  of  differentiation  between  the  two  apices.  As  a  general 
rule,  delayed  diagnosis  results  from  utter  neglect  to  take  advantage  of 
the  exact  information  afforded  by  a  few  unilateral  signs  which  are 
usually  present  and  of  supreme  importance. 

Nothing  can  he  more  erroneous  than  the  popular  notion  pertaining 
to  the  general  appearance  of  the  consumptive  and  the  exhibition  of 
the  so-called  phthisical  thorax.  While  many  pulmonary  invalids  in 
advanced  stages  are  extremely  emaciated,  with  thin,  pinched  features, 
sallow  complexion,  flushed  cheeks,  bright  eyes,  lusterless  hair,  long  thin 
necks,  and  a  suggestive  configuration  of  chest,  this  description  far  from 
represents  an  invariable  characterization  of  the  consumptive's  external 
appearance.  Such  a  clinical  picture  applies  only  to  a  comparatively 
small  proportion  of  cases.  Many  phthisical  patients  display  a  perfectly 
normal  type  of  chest,  while  the  paralytic  thorax  is  exhibited  not  infre- 
quently by  non-consumptives.  The  phthisical  chest  possesses  less  sig- 
nificance as  regards  predisposition  to  tuberculosis  than  was  formerly 
supposed.  It  is  characteristic  of  many  individuals  and  families  to  pre- 
sent a  thorax  strictly  conforming  to  this  arbitrary  type,  without  the 
slightest  semblance  to  pulmonary  infection  or  an  appreciable  impair- 
ment of  physical  strength  and  endurance. 

Waiving  a  detaOed  reference  to  the  possible  changes  observed  upon 
inspection  of  consumptives  in  general,  it  is  well,  in  the  interests  of  clear- 
ness, to  consider  separately  the  physical  signs  of  early  cases — those 
with  moderate  involvement  and  those  with  far-advanced  infection. 


CHAPTER   XXXIV 
EARLY  CASES 


In  view  of  a  somewhat  prevalent  misconception  regarding  the  rel- 
ative value  of  the  various  physical  signs,  it  may  be  asserted  that  compara- 
tively slight  importance  attaches  to  inspection,  palpation,  or  percussion 


220  PHYSICAL    SIGNS 

in  very  eaiij'  cases.  Under  these  conditions  the  tuberculous  process  is 
often  extremely  insignificant,  and  areas  of  consolidation  are  entirely 
absent.  For  this  reason  it  is  very  unusual  to  note  visual  changes  in  the 
contour  or  movement  of  the  affected  part,  palpation  also  failing  in  many 
instances  to  disclose  a  retardation  or  deficiency  of  the  inspiratory 
expansion.  Successful  percussion  of  the  two  apices  before  the  stage  of 
infiltration  is  oxceedindv  difficult.  At  a  later  period  the  detection  of 
small  areas  of  ((uisulidation  by  means  of  percussion  alone,  with  an  accu- 
rate detenniiKUioii  ol  resonant  borders,  is  an  accomplishment  to  be 
acquired  only  through  unceasing  practice. 

It  can  be  assumed  that  whenever  appreciable  deviations  from  the 
normal  are  recognized  u])on  inspection,  palpation,  and  percussion,  the 
infection  has  been  of  sufficient  duration  to  preclude  its  classification 
under  the  head  of  incipiency.  It  may  happen  that  these  methods  of 
examination  are  available  for  the  recognition  of  long-standing  tuber- 
culous proces.ses,  but  this  presupposes  an  antecedent  pulmonary  infec- 
tion involving  a  diminution  of  the  air-content.  The  visual  detection  of 
localized  change  is  possible  only  in  cases  in  which  ample  opportunity 
has  been  afforded  for  fibroid  contraction.  This  shrinkage  at  the  apex  is 
sometimes  associated  with  other  signs,  suggesting  a  tuberculous  involve- 
ment, yet  a  well-defined  retraction  indicates  clearly  the  long-continued 
existence  of  the  original  infection. 

True  incipient  cases  are  recognized  almost  solely  through  recourse 
to  auscultation.  The  prominent  auscultatory  signs,  as  a  rule,  do  not 
relate  to  changes  in  pitch,  quality,  rhythm,  or  intensity  of  the  respira- 
tory sounds,  but  consist  of  fine  crackling  rales  heard  chiefly  at  the  end  of 
insTpiration  joUowing  a  cough.  These  adventitious  sounds  are  heard 
as  very  fine  moist  bubbles  or  as  semidry  clicks,  occurring  at  the  very 
end  of  inspiration,  and  usually  absent  upon  ordinary  quiet  respiration. 
While  forced  breathing  without  cough  often  fails  to  elicit  their  pres- 
ence in  very  early  cases,  a  slight  cough  followed  by  a  moderately  sharp 
inspiration  permits  their  ready  recognition.  Care  should  be  taken  to 
prevent  a  too  violent  cough  or  unduly  vigorous  inspiratory  effort  lest 
the  finer  adventitious  sounds  be  thus  obscured.  It  is  essential,  how- 
ever, that  the  act  of  inspiration  be  sufficiently  pronounced  to  agitate 
the  secretion  in  the  finer  bronchioles.  A  momentary  pause  following 
the  cough  and  preceding  the  inspiration  facilitates  the  detection  of 
the  rales.  The  inspiration  should  be  taken  with  the  mouth  open, 
rather  than  through  the  nostrils.  Confusion  sometimes  ari.ses  from 
hearing  a  momentary  click,  which  disappears  after  the  first  two  or  three 
coughs,  and  is  due  to  a  partial  atelectatic  condition  prior  to  the  sharp 
inspirations.  Persisting  sharply  localized  unilateral  rales  may  usually  be 
regarded  as  pathognomonic  of  tuberculosis.  It  is  generally  believed 
that  the  especial  significance  of  these  rales  with  reference  to  tuberculous 
involvement  relates  to  their  recognition  in  one  apex.  While  this  is  the 
more  common  site  of  their  occurrence,  it  is,  nevertheless,  true  that  they 
may  be  found  under  the  clavicle,  in  the  axilla,  and  in  the  upper  inter- 
scapular space,  frequently  opposite  the  spine  of  the  scapula.  Some- 
times they  may  be  detected  in  that  portion  of  the  lung  overlapping  the 
apex  of  the  heart — the  lingula  pulmonalis.  While  the  recognition  of 
rales  in  this  region  may  suggest  the  possibility  of  their  pletiral  origin,  an 
assumption  as  to  a  possible  tulierculous  invasion  is  justified  to  but  a 
.slightly  less  extent.     In  Fig.  36  is  shown  a  small  area  of  tuberculous 


EARLY    CASES  221 

involvement  in  the  right  interscapular  region.  The  signs  consist  solely 
of  faint,  scarcely  recognizable  clicks  at  the  end  of  inspiration,  following 
a  cough.  There  are  no  physical  evidences  of  infiltration,  the  jiitch, 
quality,  and  rhythm  being  entirely  normal.  It  is  interesting  to  note  the 
entire  absence  of  signs  at  the  apex.  A  striking  confirmation  of  the 
physical  findings  was  subsequently  afforded  by  the  x-ray  picture  shown 
in  Fig.  49. 

In  emphasizing  the  vast  importance  of  rales  as  a  factor  of  early 
diagnosis,  due  cognizance  is  taken  of  the  conflicting  opinions  entertained 
by  other  ohservers.  Some  regard  a  roughened  breathing,  variously 
termed  "cog-wheel"  or  "harsii"  rospii'ation,  as  of  paramount  value  in 
the  early  determination  of  tubcrculcnis  lesions.  The  descriptive  appell- 
ation "harsh"  .should  relate  strictly  to  increased  intensity.  It  is  diffi- 
cult to  ascertain  precisely  what  is  meant  if  this  is  applied  to  changes  of 
pitch  or  quality.     If  it  be  assumed  that  certain  modifications  of  normal 


Fig.  36.— Photograph  of  back.  shov. 


breath-sounds  ai-e  recognized  which  are  scarcely  appropriate  for  classi- 
fication under  bronchovesicular  respiration,  it  is  affirmed,  contrary 
opinion  notwithstanding,  that  their  significance  is  decidedly  inferior  to 
that  of  localized  rales,  which  are  so  frequently  overlooked.  Cog-wheel 
or  interrupted  respiration  unassociated  with  other  signs  has  been 
described  as  of  extremely  doubtful  value,  although  considerable  impor- 
tance has  been  attached  to  this  sign  in  the  ])ast.  .lerky  respiration 
may  be  suggestive  of  a  catarrhal  iiivnjxcniciit  o(  the  finer  tubes,  but 
when  preisent  at  one  apex,  to  the  exclusion  of  the  other,  even  without 
crackling  rales,  justly  affords  a  strong  suspicion  of  incipient  tuber- 
culosis. It  is  interesting,  in  reviewing  charts  presented  by  pulmonary 
invalids,  to  note  the  multiplicity  of  detail  with  reference  to  the  finer 
shades  of  respiratory  sounds  in  various  parts  of  the  chest,  in  connection 
with  an  amazing  failure  to  recognize  the  distinct  crackles  upon  cough. 
This  frequent  neglect  to  record  the  pre.sence  of  rales  in  the  apical  regions 
obtains  to  an  equal,  if  not  greater,  extent  heijond  the  recognized  borders 


222  PHYSICAL    SIGNS 

of  tuberculous  infection.  Careful  auscultation  often  fails  to  reveal  the 
existence  even  of  slight  deviation  from  the  normal  respiratory  sounds 
in  such  locations,  while  rales  are  easily  elicited  by  the  act  of  coughing. 
It  is  a  source  of  considerable  surprise  to  learn  from  observation  that 
a  large  number  of  clinicians  fail  to  take  advantage  of  the  assistance  to 
be  afforded  by  a  gentle  cough.  A  few  are  known  to  assert  that  rales 
are  disclosed  with  greater  ease  and  accuracy  upon  easy  respiration. 
For  general  application  such  statements  are  illusory  in  the  extreme, 
though  occasionally  a  fine  click  may  be  detected  after  an  initial  cough, 
only  to  disappear  subsequently  upon  the  temporary  dislodgment  of 
secretion. 

Save  in  the  presence  of  tolerably  well-defined  areas  of  consolidation, 
important  modifications  of  the  normal  respiratory  sounds  without  rales 
are  exceedingly  rare  in  early  cases.  While  noticeable  infiltration  of  one 
apex  may  occasionally  be  found  in  the  absence  of  rales,  adventitious 
sounds  are  usually  capable  of  recognition  if  proper  means  are  taken  to 
elicit  their  presence. 

The  most  important  unilateral  modifications  of  normal  respiratory 
sounds  are  the  relative  elevation  of  pitch,  prolongation  of  expiration, 
and  added  element  of  tubular  quality.  The  actual  import  of  this 
approach  to  bronchial  breathing  depends  largely  upon  a  comparison  of 
the  respiratory  sound  at  one  apex  with  that  obtained  upon  the  oppo- 
site side.  Thus  the  character  of  the  respiration  is  of  relative  rather  than 
of  absolute  value,  and  is  of  especial  importance  according  to  its  location 
at  the  right  or  left  apex.  Attention  has  been  called  in  previous  chapters 
to  the  norynal  dispariti/  between  the  two  apices,  particularly  with  refer- 
ence to  the  elevation  of  pitch,  the  slightly  tubular  quality,  and  the  pro- 
longation of  expiration  upon  the  right  side  in  health.  It  is  thus 
impossible  in  some  cases  to  determine  with  accuracy  if  slight  modifica- 
tions of  the  respiratory  sounds  upon  this  side  do  not  occur  as  a  simple 
exaggeration  of  the  physiologic  difference  between  the  two  apices.  The 
significance  of  these  signs,  however,  at  the  left  apex  is  quite  conclusive 
in  denoting  the  existence  of  tuberculous  infection.  Equal  importance 
may  be  attached  to  increased  vocal  resonance  at  the  left  apex,  but  its 
interpretation,  if  recognized  upon  the  right  side,  is  often  illusory. 

Some  writers  have  attached  considerable  importance  in  early  tuber- 
culosis to  the  detection  of  impaired  respiratory  mobility  upon  one  side, 
as  shown  by  a  diminished  movement  of  the  diaphragm.  The  descent 
of  the  diaphragm  may  be  found  to  be  incomplete  unilaterally  or 
simply  retarded  in  time.  As  studied  by  the  fluoroscope,  the  difference 
in  time  may  be  noted  by  comparing  simultaneously  the  movement  of 
the  diaphragm  upon  the  two  sides.  The  extent  of  the  diaphragmatic 
movement  can  be  observed  fairly  accurately  by  using  the  method  of 
Litten,  described  on  p.  170,  and  marking  the  skin  with  ink  and  com- 
paring the  two  sides,  but  this  method  affords  no  opportunity  to  note  a 
unilateral  retardation  of  movement.  Generally  speaking,  a  slight  devia- 
tion from  the  normal  descent  of  the  diaphragm  is  more  a  matter  of  clin- 
ical interest  than  of  practical  diagnostic  value  in  early  tuberculosis, 
as  this  is  often  due  to  old  pleuritic  adhesions.  An  existing  tuberculous 
infection  sufficient  to  produce  noticeable  impairment  or  retardation  of 
the  diaphragmatic  movements  usually  permits  a  ready  diagnosis  from 
jihysical  exploration. 


CASES    WITH    MODERATE    INVOLVEMENT  226 

CHAPTER  XXXV 
CASES  WITH  MODERATE  INVOLVEMENT 

For  present  purposes  a  moderate  tuberculous  involvement  of  the  lung 
may  be  defined  as  a  partial  non-extensive  consolidation,  with  moisture  in 
the  bronchial  tubes  throughout  the  infected  area.  Cases  of  pulmonary 
tuberculosis  belonging  to  this  class  do  not  display  physical  evidences 
of  softening  or  excavation,  as  such  signs  are  characteristic  of  more 
advanced  infection.  Manifestly,  it  is  impossible  to  divide  all  cases  of 
consumption  into  three  arbitrary  divisions.  Many  cases  will  be  found 
extremely  diflficult  of  classification,  because  of  the  complex  and  divergent 
nature  of  the  physical  conditions.  In  the  same  individual  there  may  be 
exhibited  an  area  of  incipient  infection;  in  another  region,  a  tuberculous 
process  of  distinctly  moderate  type;  and  elsewhere  signs  of  cavity  for- 
mation peculiar  to  far-advanced  cases.  A  definition  of  the  various 
typBS  of  pulmonary  tuberculosis  takes  cognizance  not  only  of  the  nature 
of  the  process  and  the  extent  of  its  distribution,  but  also  the  degree  of 
its  activity.  Thus  the  physical  findings  may  chsclose  a  definite  morbid 
change  in  the  anatomy  of  the  lung,  either  of  small  or  large  size,  and  yet 
suggest  no  existing  activity  of  the  tuberculous  process.  Obviously,  such 
cases  presenting  corroborative  subjective  and  bacteriologic  evidences 
are  not  to  be  included  in  the  classification  of  early,  moderate,  or  advanced 
cases,  but  comprise  strictly  a  class  l)y  themselves,  to  be  designated 
"arrested  cases."  The  degree  of  actirilij  iiiini  l>r  imasured  to  a  great 
extent  by  the  amount  of  moisture  in  the  lironcliinl  tul)cs.  In  cases 
of  moderate  tuberculous  infection  the  air-content  in  a  given  area  is 
diminished  by  virtue  of  a  partial  consolidation  of  lung.  As  a  direct 
result  of  the  abnormality  of  tissue,  cUstinctive  changes  are  recognized 
in  the  physical  signs. 

Upon  inspection  there  is  rarely  noted  in  individuals  conforming 
strictly  to  this  class  a  marked  degree  of  emaciation,  pallor,  dyspnea,  or 
cyanosis.  There  may  be  slight  flushing  of  the  cheeks,  according  to  the 
extent  of  vasomotor  disturbance,  and  moderate  loss  of  weight,  but  the 
more  important  visual  appearances  are  referable  to  the  thorax  proper. 
These  changes  are  often  sharply  localized,  and  consist  of  unilateral  devia- 
tions from  the  normal  contour  of  the  chest  and  of  arrhythmic  respira- 
tory movements.  Inasmuch  as  the  tuberculous  process  usually  elects 
the  apex  as  its  favorite  site  of  invasion,  the  asymmetric  conditions  are 
observed  more  frequently  in  the  upper  portion  of  the  chest.  Conspicu- 
ous retraction  of  the  supraclavicular  fossa  is  often  accompanied  by 
flattening  of  the  chest  immediately  below  the  clavicle.  This  Stands  out 
with  greater  prominence  than  its  fellow  of  the  opposite  side,  and  the 
acromial  end  is  appreciably  elevated.  The  upper  intercostal  spaces  may 
liecome  accentuated  from  atrophy  of  the  thoracic  muscles  upon  the 
affected  side,  and  a  characteristic  drooping  of  the  shoulders  may  be 
noted,  although  less  frequently  than  among  cases  with  advanced  infec- 
tion. In  addition  to  the  altered  configuration  of  the  upper  part  of  the 
thorax  there  may  be  observed  localized  impairment  of  respiration.  In 
some  cases  this  may  consist  of  a  diminished  respiratory  excursion,  and 
in  others  of  a  retardation  of  the  movement.  While  irregularity  of  con- 
tour is    readily  noted   upon  casual    observation,  a  rigid   comparative 


224  PHYSICAL    SIGNS 

scrutiny  of  the  two  sides  is  sometimes  necessary  to  detect  changes  in  the 
respiratory  movement.  They  are  recognized  more  easily  if  inspection  be 
made  with  the  examiner  standing  behind  the  patient  and  looking  over 
the  shoulders,  to  observe  the  simultaneous  bilateral  excursions.  A  dis- 
tinct apex  retraction  is  indicative  of  a  long-standing  lesion,  while  a  mere 
retardation  of  movement  without  retraction  suggests  the  existence  of  a 
recent  infection. 

Palpation  may  confirm  the  results  of  inspection  with  reference  both 
to  contour  changes  and  to  modifications  of  the  normal  respiratory  act. 
It  may  be  practised  by  laying  the  tips  of  the  fingers  in  the  supracla- 
vicular fossa,  with  the  thumb  upon  the  vertebra,  the  patient  in  the 
sitting  position,  and  the  physician  standing  behind.  In  this  manner 
differences  in  the  inspiratory  expansion  at  the  apices  are  noted  with- 
out difficulty.  Information  may  be  secured  not  only  with  respect  to 
inequalities  of  respiratory  excursion,  but  also  as  to  the  degree  of  con- 
solidation, by  virtue  of  the  more  ready  transmission  of  voice-sounds 
through  a  partially  solid  medium.  This  is  subject  to  considerable 
variation,  as  has  been  described  in  connection  with  vocal  fremitus. 

The  percussion  signs  in  cases  of  moderate  tuberculous  involvement 
relate  to  differences  in  quality  and  intensity  and  to  the  changed 
resonant  boundaries.  It  must  be  remembered  that  each  person  fur- 
nishes his  own  standard  of  resonance,  as  has  been  described.  As  there 
is  no  ideal  type  of  percu.ssion  resonance  common  to  all  individuals, 
deviations  from  the  normal  can  be  recognized  only  by  a  close  comparison 
of  the  two  sides.  Attention  is  again  called  to  the  necessity  of  discrimi- 
nating closely  between  the  dulness  and  elevation  of  pitch  upon  the  right 
and  left  sides  respectively.  Owing  to  the  physiologic  variation  at  the 
two  apices  a  slight  impairment  of  resonance  at  the  right  apex  is  of  much 
less  significance  than  at  the  left.  The  normal  disparity  is  such  that  it  is 
sometimes  impossible,  in  case  of  right-sided  dulness,  to  distinguish,  upon 
percussion  alone,  between  a  possible  exaggeration  of  the  dissimilarity  in 
health  and  a  localized  tuberculous  infection.  Dulness  at  the  left  apex, 
however,  is  highly  significant  of  tuberculous  change.  Difficulty  may 
arise  in  recognizing  the  dulness  incident  to  small  areas  of  tubercle 
deposit,  owing  to  tlie  vicarious  emphysema  of  adjacent  pulmonary  tissue. 

Deviations  from  the  normal  percussion  outlines,  while  of  great 
clinical  interest  in  the  more  advanced  cases,  particularly  if  associated 
with  extensive  fibrosis,  are  not  invariably  pronounced  in  instances  of 
moderate  infection.  In  such  the  variations  relate  especially  to  the 
supraclavicular  fossae.  In  health  the  lung  rises  above  each  clavicle 
to  a  distance  of  about  an  inch  and  a  half,  differences  Ijetween  the  two 
sides  being  rarely  observed.  An  appreciable  unilateral  diminution  of 
the  height  of  the  pulmonary  resonance  may  be  ascribed  to  the  shrinkage 
incident  to  tuberculous  infiltration  and  fibrosis.  The  lateral  apical 
boundary  is  of  importance,  as  well  as  the  height  of  the  resonant  lung. 
This  has  been  described  at  length  by  Kronig,  Minor,  and  other  clinicians. 
In  many  cases  of  unilateral  disease  the  diminution  of  the  resonant  area 
is  somewhat  striking.  While  it  is  impossible  to  state  with  absolute 
accuracy  that  the  shrinkage  is  of  long  standing,  it  is  undoubtedly  true 
that  in  the  majority  of  instances  the  tuberculous  process  is  of  fairly 
remote  rather  than  of  recent  origin.  It  is  more  a  matter  of  clinical 
interest  than  of  actual  diagnostic  value,  for  the  I'eason  that  a  tuberculous 
change  in  the  apex  sufficient  to  produce  a  well-defined  variation  from 


CASES    WITH    MODERATE    INVOLVEMENT  225 

the  normal  percussion  outline  must  almost  invariably  be  attended  with 
auscultatory  signs  capable  of  ready  recognition. 

A  pronounced  disparity  between  the  apical  percussion  boundaries 
upon  the  two  sides  may  exist  in  the  entire  absence  of  tubercle  deposit. 
Recently  I  have  had  occasion  to  note  a  conspicuous  instance  of  apical 
shrinkage  as  determined  upon  percus.sion,  which,  without  the  aid  of  the 
a:-ray,  would  have  led  to  a  deplorable  error  of  diagnosis. 

A  man  of  twenty-five  with  an  unfortunate  family  history  of  tuber- 
culosis accompanied  to  Colorado,  in  the  latter  part  of  1906,  a  sister 
in  advanced  phthisis.  The  patient  speedily  succumbed  to  the  disease, 
and  the  survivor  presented  himself  for  examination  and  opinion  before 
venturing  to  return  permanently  to  an  unfavorable  climate.  There 
were  no  symptoms  suggestive  of  pulmonary  involvement,  and  the 
physical  examination  was  negative,  save  for  a  well-defined  dissimilarity 
in  the  apical  jjercussion  boundaries.  The  e.xtent  of  shrinkage  at  the  right 
apex  is  shown  in  the  ;icconijiunying  phototjraph  (Fig.  37).     Upon  j-ray 


the  apical  percussion  outlines,  suggesting  a  tuberci 
ticonfirmed  Dy  j-ray  examination.     (See  radiograph, 


Fig.  44.) 


examination,  however,  it  was  found  that  a  well-marked  thickening  of 
the  right  mediastinal  pleura  had  taken  place,  resulting  in  pronounced 
traction  upon  the  pulmonary  tissues  at  the  apex,  without  evidence  of 
tubercle  depo.sit.  The  skiagraph  (Fig.  44)  is  presented  upon  p.  252. 
In  this  connection  an  interesting  clinical  phenomenon  is  shown  in 
Fig.  38,  which  illustrates  a  very  material  apical  shrinkage  noted 
upon  inspection.  The  patient,  aged  twenty,  was  sent  to  Colorado 
January  17,  1907.  In  spite  of  a  loss  of  seventeen  pounds  in  weight, 
with  persisting  fever  anfl  slight  cough,  the  physical  and  bacteriologic 
examinations  failed  to  disclose  the  slightest  evidences  of  tuberculous 
infection.  The  apical  percussion  borders  were  perfectly  normal,  despite 
the  extreme  visible  retraction  upon  the  right  side.  Another  patient,  aged 
twenty-seven,  arrived  in  Colorado  in  the  latter  part  of  1907  with  dis- 
tinct physical  evidences  of  pulmonary  tuberculosis.  The  shrinkage 
of  apical  percussion  boundaries  was  pronounced  at  the  right  apex, 
15 


226 


PHYSICAL    SIGNS 


although  the  other  physical  signs  pointed  to  an  absence  of  tuberculous 
infection  at  this  region.  Signs  of  slight  infiltration  with  moisture  were 
detected,  however,  in  the  left  lung,  especially  from  the  third  rib  to  the 


Fig.  38.— PronouiiL-ed 


right  apex,  without  tuberculous  involv 


base.  Upon  .r-ray  examination  it  wa.s  found  that  the  tuberculous  process 
was  limited  solely  to  the  left  lung,  without  evidence  of  apical  involve- 
ment upon  either  side.  The  extent  of  the  dissimilarity  of  percussion  out- 
lines at  the  apex  is  shown  in  Fig.  39.     In  Fig.  6  are  shown  practically 


Fig.  39. — Pronounced  shrinkage  of  the  outline  of  percussion 
absence  of  tuberculous  involvement  in  this  region.  Pliysical  ev 
perfectly  detined  in  left  lung.      (Compare  with  radiograph,  Fig.  53. 


uniform  resonant  boundaries  at  the  two  apices  upon  careful  percussion. 
If  anjrthing,  the  area  of  resonance  was  slightly  smaller  at  the  right  apex. 
Reference,  however,  to  the  skiagraph  (Fig.  45)  reveals  an  appreciable 


CASES    WITH    MODERATE    INVOLVEMENT  227 

shadow  at  the  right  apex,  suggesting  the  liiveliliood  of  a  greater  dif- 
ference in  the  percussion  borders  than  was  found  to  exist.  A  patient, 
aged  twenty-eight,  was  sent  to  Colorado  in  October,  1907,  for  sus- 
pected pulmonary  tuberculosis,  presenting  a  history  of  pulmonary 
hemorrhage.  Despite  a  well-marked  shrinkage  in  the  outline  of  per- 
cussion resonance  at  the  left  apex,  physical  examination  of  the  chest 
was  in  other  respects  entirely  negative.  The  bacteriologic  fincUngs 
were  also  negative.  After  several  weeks  a  pronounced  hemoptysis 
took  place,  apparently  adding  to  the  significance  attaching  to  an 
unquestioned  disparity  in  the  apical  outlines.  The  outlines  of  per- 
cvission  resonance  upon  the  two  sides  are  shown  in  Fig.  40.  As 
illustrative  of  the  very  pronounced  unilateral  apical  shrinkage  in 
connection  with  advanced  tuberculous  change  the  following  case  is 
of  some  interest.     A  young  man  came  under  my  observation  in  the 


Fig.  40. — Easily  recognized  change 


summer  of  1907,  presenting  physical  evidcuics  of  rather  extensive 
tuberculous  involvement  of  the  right  huii;.  witli  slight  infiltration  in 
the  upper  left.  The  extent  of  visual  unilateral  ictraction  may  be  noted 
by  reference  to  the  accompanying  photograph  (Fig.  41).  By  comparing 
with  Fig.  56,  an  explanation  of  the  shrinkage  is  found  in  the  destructive 
tuberculous  change  at  the  apex.  In  view  of  the  experience  afforded 
by  the  observation  of  the  above  and  similar  cases,  it  is  apparent  that 
the  .significance  of  the  percussioti  outlines  at  the  apices  is  subject  to 
considerable  variation. 

The  auscultatory  signs  of  moderate  infection  are  modifications  of  the 
normal  respiratory  murmur,  advontitiou.^  sounds  or  rales,  changes  in  the 
vocal  resonance  and  in  the  whispered  voice. 

Modifications  of  the  normal  respiratory  sounds  partake  of  the 
general  type  of  bronchovesicular  respiration,  which  has  been  described. 


228  PHYSICAL    SIGNS 

True  bronchial  breathing  is  rarely  observed  in  cases  of  partial  con- 
solidation, although  the  bronchial  element  may  markecUy  predominate 
over  the  vesicular.  The  changes  relating  to  intensitj',  pitch,  duration, 
and  quality  of  the  inspiratory  and  expiratory  sounds  have  been  dwelt 
upon  at  such  length  in  the  preceding  chapters  that  further  description 
is  unnecessary.  It  must  be  remembered  that  the  recognition  of  bron- 
chovesicular  breathing  at  the  right  apex  is  possessed  of  far  less  signifi- 
cance than  at  the  left,  owing  to  the  physiologic  difference  between  the 
two  apices. 

The  adventitious  sounds  or  rales  incident  to  this  class  of  cases 
may  assume  the  same  general  characteristics  as  those  occurring  in 
incipient  stages,  being  of  an  explosive,  crackling  type  and  recognized  at 
the  end  of  inspiration  following  a  cough.  More  frequently,  however,  they 
are  distinctl}'  moist  and  bubbling,  exhibiting  variations  in  size  and 
easily  appreciable  without  cougli  during  expii-ation  as  well  as  inspiration. 


Fig.  41. — Pronounced  visual  retraction,   right  apex.      (Compare  witli  cavity  formation  shown 


The  rales  may  be  elevated  in  pitch  and  consonating  in  character,  denoting 
their  origin  in  bronchial  tubes  surrounded  by  indurated  pulmonary 
tissue. 

The  physical  signs  pertaining  to  the  spoken  voice  represent  impor- 
tant changes  in  the  vocal  resonance  over  the  partially  solidified  lung. 
The  degree  to  which  the  voice-sounds  are  exaggerated  in  intensity  and 
modified  in  pitch  and  quality,  has  lieen  explained  to  vary  materially 
according  to  the  extent  of  con.sojidation.  A  very  important  sign  is  the 
inten.sification  of  the  whispered  voice  in  the  presence  of  slightly  con- 
solidated lung.  This  increased  transmission,  together  with  a  slight 
elevation  of  pitch  and  change  of  quality,  antedates  considerably  the 
recognition  of  bronchovesicular  breathing. 

It  is  sometimes  possible  to  detect  an  increased  intensity  of  the 
normal  heart-sounds  on  account  of  their  conduction  through  solidified 
lung. 


ADVANCED    CASES 


CHAPTER  XXXVI 
ADVANCED  CASES 


Patients  conforming  to  this  group  usually  exhibit  a  striking  com- 
bination of  physical  signs.  Exploration  of  the  chest  is  important  not 
so  much  as  a  means  of  diagnosis  as  a  matter  of  clinical  exactitude  and 
as  a  feature  of  prognosis.  Although  extensive  cavity  formation  may 
be  present  in  some  individuals  exhibiting  every  external  evidence  of 
health  and  vigor,  yet  in  a  large  number  of  cases  the  general  appearance 
of  the  patient  is  highly  suggestive  of  the  disease.  Emaciation,  pallor, 
dyspnea,  and  cyanosis  are  often  proiiduiiccd.  The  skin  of  the  body 
may  be  dry,  harsh,  or  even  scaly,  and  \\\c  liaiuls  thin,  cold,  and  clammy. 
The  fingers  may  be  elongated,  with  tapciiim  cxl  icmities  and  incurving 
nails,  or  the  ends  distinctly  clubbed.     The  lucU   is  thin  and  appears 


n  area  of  well-defined  visual  piU.sation  in  a  patient  w 
the  left  lung,  with  marked  fibrosis.     Note  the  slight  deflection  of  i 
toward  the  unaffected  side.    (Compare  with  radiograph,  B'ig.  79.) 


unduly  long.  The  ears  stand  out  prominently  from  the  sides  of  the 
head,  and  are  often  waxy,  bloodless,  and  almost  transparent.  The 
breathing  is  at  times  labored,  with  the  action  of  the  accessory  muscles 
of  respiration  prominently  displayed.  The  nose  may  be  pinched,  the 
eyes  sharp  and  bright,  the  hair  dry  and  lusterless,  and  the  face  pallid, 
cyanotic,  or  flushed.  The  complexion  is  sometimes  remarkably  pale  and 
clear,  exhibiting  strikiiiiily  a  delicate  plexus  of  superficial  veins.  The 
patient  fi-e(|uen11y  assumes  a,  piniKiuuced  stonpiug  posture,  the  general 
attitude  being  that  oi  iiuuked  debility.  In  addition  to  the  drooping  of 
the  shoulders,  the  pcapulse  are  very  conspicuous  and  suggest  the  oft-noted 
resemblance    to    wings.     The    changes    noted    upon    inspection,    with 


230  PHYSICAL    SIGNS 

especial  reference  to  the  thorax,  aside  from  its  occasional  conformity  to 
the  phthisical  habitus,  partake  chiefly  of  flattenmg,  retraction,  and 
impaired  mobility.  These  differences  may  affect  chiefly  one  side  or 
involve  the  entire  chest.  Unilateral  shrinkage  may  be  sufficient  to 
transform  completely  the  contour  of  the  thorax  and  greatly  restrict 
the  respiratory  excursion.  There  may  be  resulting  curvature  of  the 
spine  and  dislocation  of  the  sternum.  If  the  contraction  change  is 
present  to  a  marked  degree  upon  the  left  side,  a  large  portion  of  the 
heart  is  denuded  of  its  pulmonary  covering,  and  there  result  visual 
pulsations  in  the  third  or  fourth  interspaces.  The  cardiac  apex  impulse 
is  also  subject  to  considerable  dislocation,  being  pulled  toward  the 
affected  side,  as  has  been  described. 

The  changes  observed  upon  inspection  are  subject  to  ready  con- 
firmation by  palpation,  which  also  serves  to  elicit  certain  points 
of  tenderness  and  a  notably  increased  fremitus.      Rhonchi  from  the 


Fig.  43. — Representing  visual  cardiac  impulse  in  a  patient  witli  ver>-  advanced  tuberculous 
change  in  the  left  lung.  The  tuberculous  process  in  this  lung  has  been  of  long  duration,  and  the 
fibroid  contractile  change  is  very  pronounced.  The  wavy,  undulatory  impulse  is  detected  through- 
out the  larger  circle,  whereas  the  inner  represents  the  location  of  a  very  pronounced  impulse. 

bronchial  tubes  may  be  recognized  in  some  cases  with  the  hand  laid 
against  the  chest- wall. 

Percussion  may  yield  information  of  a  varied  and  definite  character, 
but  this  method  of  examination  alone  is  incapable  of  affording  an  exact 
diagnosis  of  the  morbid  pulmonary  conditions.  In  advanced  consump- 
tion percussion  changes  may  relate  to  the  entire  disappearance  of  pulmo- 
nary resonance,  diminution  of  inten.sity,  elevation  of  pitch,  and  cUffer- 
ences  of  quality. 

Total  flatness  results  from  an  area  of  complete  pulmonary  con- 
solidation, but  it  is  seldom  that  a  single  lung  is  solidified  to  the  same 
degree  throughout  its  entire  area.  Complete  absence  of  resonance  in 
pulmonary  tuberculosis  may  also  be  due  to  complicating  pleural  effu- 
sions or  pneumopyothorax,  as  well  as  to  solid  lung  and  thickened  pleura. 

Diminished  intensity  of  pulmonary  resonance  exists  wherever  the 
air-content  is  appreciably  les.sened  in  a  given  portion  of  the  chest,  and 
is  observed  in  connection  with  an  elevation  of  pitch.  Small  deei)-seated 
areas  of  partial  consolidation  may  escape  detection  because  of  the  reso- 
nance of  intervening  normal  lung  tissue.     Therefore  the  location  and 


ADVANCED    CASES  231 

size  of  the  involvement  are  factors  of  considerable  importance  as  regards 
the  resulting  changes  in  percussion  resonance.  Owing  to  the  thick 
muscles  of  the  back,  it  is  impossible  to  elicit  dulness  upon  gentle  per- 
cussion unless  the  area  of  consolidation  be  of  considerable  size.  Save 
at  the  apices,  it  is  doubtful  if  changes  of  percussion  resonance  can  be 
noted  over  a  superficial  area  of  less  than  four  or  five  centimeters  in 
diameter,  or  at  a  depth  of  over  four  or  five  centimeters  from  the  surface. 
The  manner  of  percussion  and  the  variations  of  resonance  have  already 
been  sufficiently  discussed. 

Differences  in  quality  involve  necessarily  a  diminution  of  the  vesicu- 
lar element  and  a  corresponding  increase  of  the  tympanitic.  Owing 
to  the  varied  physical  conditions  obtaining  in  the  midst  of  the  destruc- 
tive change  incident  to  advanced  consumption,  the  resonance  may  be 
purely  tympanitic,  assume  the  cracked-pot  character,  or  present  an 
amphoric  intonation.  Strictly  speaking,  the  cracked-pot  and  the 
amphoric  resonance  constitute  forms  of  the  tympanitic,  differing  from 
it  only  by  virtue  of  certain  modifying  attributes.  In  consumption  the 
recognition  of  any  one  of  these  three  varieties  is  suggestive  of  the  pres- 
ence of  a  pulmonary  cavity.  As  has  been  shown,  however,  percussion 
signs  are  of  but  little  value  in  the  determination  of  this  condition.  The 
purely  tympanitic  type  may  occasionally  be  observed  in  late  consump- 
tion over  large  cavities,  and  rarely  over  a  consolidated  upper  lobe,  as  a 
result  of  the  transmission  of  air  vibrations  from  the  trachea  and  primary 
bronchi. 

The  descriptive  appellation  "  cracked-pot' '  resonance  has  frequently 
Ijecn  iciianlcil  as  definitely  pathognomonic  of  pulmonary  excavation. 
While  this  ,si,i^u  may  be  elicited  now  and  then  in  the  percussion  of  pul- 
HKjuary  cavities,  it  represents  but  comparatively  little  value  as  a  cavity 
sign  per  se.  As  previously  stated,  it  is  frequently  absent  over  pulmonary 
cavities,  and  is  often  obtained  when  no  cavity  exists. 

The  conditions  responsible  for  the  production  of  the  peculiar  musical 
intonation  characterizing  amphoric  resonance  have  been  described. 

In  addition  to  elevations  of  pitch  commonly  noted  over  consolidated 
lung,  certain  modifications  are  sometimes  recognized  over  localized 
areas  in  the  later  stages  of  consumption.  The  various  changes  of  pitch 
elicited  during  percussion  of  pulmonary  cavities  have  been  described 
sufficiently  under  General  Physical  Signs. 

In  the  midst  of  extensive  fibrosis  the  normal  percussion  boundaries 
are  sometimes  distorted  to  a  remarkable  extent,  this  being  particularly 
true  of  the  heart. 

The  influence  of  intrapleural  conditions  in  producing  changes  of 
percussion  outlines  will  be  discussed  in  connection  with  Complications. 

Upon  auscultation  in  the  miflst  of  advanced  infection  there  may 
be  found  the  greatest  ]H,ssili|c  drxiatiou  lioni  the  normal  respira- 
tory sounds  and  those  of  tlic  sjiuki'ii  ami  wliispered  voice.  The  inten- 
sity of  the  breath-sounds  may  lie  diininislied  in  some  cases  through 
narrowing  of  the  lumen  of  the  bronchi  from  tubercle  deposit,  and  in 
others  through  the  accumulation  of  thick,  tenacious  secretions  in  the 
tubes.  They  are  reduced  at  times  by  an  associated  omphysema,  an 
accompanying  pleural  effusion,  or  extensive  plemiiii'  adhc-ions.  In 
addition  to  the  marked  thickening  of  the  pleura  with  coiii  rui  tiim  changes 
incident  to  fibrous  tissue  proliferation,  there  may  exist  an  obliteration 
of  terminal   bronchioles  as  a  result  of  the   cicatrizing   process.     The 


232  PHYSICAL    SIGNS 

breath-sounds  are  rarely  suppressed  altogether  in  consumption,  though 
this  may  result  upon  one  side  from  the  temporary'  occlusion  of  a  bronchial 
tube.  They  maj-  be  absent  also  in  areas  of  complete  pneumonic  consoli- 
dation, excessive  fibroid  change,  pleurisy  with  large  effusion,  closed  pneu- 
mothorax or  pyopneumothorax,  and  severe  pulmonary  edema.  Among 
consumptives  an  increased  intensity  of  the  respiratory  sounds  may  be 
recognized  in  one  lung  when  the  respiratory  function  of  the  other  is 
impaired  to  a  great  extent  as  the  result  of  disease.  This  vicarious  or 
supplemental  type  of  respiration  may  obtain  over  small  localized  areas, 
not  uncommonly  at  the  apices,  and  is  due  to  the  compensatory  activity 
of  the  non-tuberculous  tissue.  It  is  rarely  recognized  by  clinicians  over 
circumscribed  regions,  although  patches  of  emphysema  in  tuberculous 
lungs  are  exceedingly  numerous  at  autopsy.  The  chief  distinguishing 
characteristics  of  the  bi-eath-sounds  in  advanced  phthisis  relate  to 
changes  in  pitch  and  quality,  which  are  included  under  bronchial,  bron- 
chovesicular,  cavernous,  amphoric,  and  the  metamoi-phosing  respiration. 
These  types  of  breathing  have  been  described  at  length  under  the  Gen- 
eral Physical  Signs. 

Changes  in  the  duration  of  the  sounds  are  sometimes  observed,  but 
these  are  of  slight  practical  importance  in  comparison  with  the  more 
striking  respiratory  changes  during  advanced  tuberculous  involvement. 
Interest  attaches  to  the  shortening  of  the  in.spiration  and  the  prolon- 
gation of  the  expiration  incident  to  bronchial  breathing,  and  the  length- 
ened expiration  of  cavernous  respiration. 

The  rales  of  ad\'anced  phthisis  are  of  medium  size  or  coarse,  and 
bubbling  or  gurgling  in  character,  in  contradistinction  to  the  finer  clicks 
or  crackles  recognized  in  early  cases.  They  are  heard  upon  easy  breath- 
ing, the  cough  being  by  no  means  a  necessary  factor  for  their  production, 
save  in  areas  of  recent  involvement.  They  are  high  in  pitch  in  pro- 
portion to  the  degree  of  pulmonary  consolidation.  The  adventitious 
sounds  do  not,  as  a  rule,  dcihe  their  origin  from  the  finer  tubes,  except 
in  freshly  infected  icuidn-;.  The  size  of  the  rale  corresponds  to  the  size 
of  the  tubes  and  tlic  |iiiliii()ii;ii\-  cavities  from  which  the  sounds  emanate. 
When  the  cavity  ha^  atiaiiiiMl  a  fair  size,  the  rale  becomes  gurgling  in 
character  and  metallic  tinkling  is  not  altogether  uncommon. 

The  vocal  resonance  i~  usually  nuich  intensified  in  advanced  phthisis. 
As  a  result  of  the  consolidation  of  lung  or  the  pre.sence  of  pulmonary  cavi- 
ties, changes  in  the  pitch  and  ciuality  of  the  spoken  voice  are  also  recog- 
nized, characterizing  bronchophon}-  and  pectoriloquy.  While  the  sound 
heard  over  cavities  in  the  midst  of  pulmonary  consolidation  may  par- 
take of  the  bronchophonic  character  to  some  extent,  bronchojjhony  is 
heard  chiefly  over  soliilified  lung.  In  the  same  manner  pectoriloquy 
may  be  recognized  over  areas  of  both  consolidation  and  excavation. 

Attention  has  been  called  to  the  changes  in  the  whispered  voice 
as  a  result  of  tuberculous  infiltration  and  cavity  formation.  Pulmonary 
cavities  may  occasion  a  marked  increase  in  the  intensity  of  the  whispered 
voice,  without  necessarily  invoh'ing  appreciable  changes  in  pitch  and 
quality.  Over  thoroughly  consolidated  areas,  howe\-er,  the  whispered 
resonance  becomes  high  pitched  and  tubular  in  quality,  corresponding 
to  the  sound  of  expiration  in  bronchial  breathing.  Whispering  pecto- 
riloquy and  the  whispered  amphoric  echo  maj'  also  be  recognized.  It 
may  be  well  to  recapitulate  briefly  the  physical  signs  of  pulmonary 
cavities,  but  it  must  be  remembered  that  their  recognition  in  many 


ADVANCED    CASES  233 

cases  is  not  nearly  so  simple  as  would  appear  from  text-book  descrip- 
tion. There  may  be  detected  occasionally,  upon  percussion,  tympanitic 
resonance,  amphoric  resonance,  or  cracked-pot  resonance;  Wintrich's 
change  of  pitch;  Wintrich's  interrupted  change  of  pitch;  or  Gerhardt's 
change  of  pitch.  Upon  auscultation  there  may  be  elicited  cavernous 
breathing,  vesiculocavernous  breathing,  bronchocavernous  breathing, 
amphoric  breathing,  gurgling  cavernous  rales,  metallic  tinkling,  increased 
vocal  resonance,  with  or  without  bronchophonic  characteristics,  pecto- 
riloquy, amphoric  voice,  the  cavernous  whisper,  and  whispering  pecto- 
riloquy. 

Many  of  these  signs  may  be  recognized  under  conditions  other  than 
pulmonary  excavation,  and,  on  the  other  hand,  cavities. may  exist  with- 
out the  recognition  of  a  single  physical  sign.  They  may  be  detected 
with  ease  at  certain  periods  and  escape  recognition  at  other  times.  The 
very  fact  of  the  interraittency  of  the  physical  signs  furnishes  exceed- 
ingly strong  evidence  of  pulmonary  excavation.  Failure  to  recognize 
the  physical  signs  in  such  cases  is  explained  either  by  the  presence  of 
large  masses  of  mucopus  in  the  tubes,  completely  obliterating  their  cali- 
ber, or  by  the  filling  of  the  cavity  itself  with  purulent  secretion. 


PART   IV 
DIAGNOSIS  AND   PROGNOSIS 

SECTION    I 
Diagnosis 


CITAPTER  XXXVU 
PRELIMINARY  CONSIDERATIONS 

Diagnosis  is  by  far  the  most  important  consideration  pertaining 
to  the  general  subject  of  pulmonar}-  tuberculosis.  In  no  other  disease 
is  this  of  more  surpassing  moment.  It  is  scarcely  conceivable  that  any 
uncertainty  should  exist  in  the  recognition  of  moderately  advanced 
phthisis,  for  the  history,  subjective  sj-mptoms,  and  physical  signs 
present  a  clinical  picture  so  typical  as  almost  to  preclude  the  possibility 
of  error.  Even  when  the  constitutional  symptoms  are,  perhaps,  of 
doubtful  import,  the  diagnosis  is  comparatively  simple  in  the  vast 
majority  of  instances  through  recourse  to  the  physical  signs,  bacteriologic 
evidences,  .r-ray  examination,  and,  when  necessary,  the  tuberculin 
tests.  The  incipient  cases  present  the  only  reasonable  difSculties  in  the 
way  of  accurate  diagnosis,  and  it  is  in  precisely  this  class  that  the  early 
recognition  of  the  disease  is  of  the  utmost  consequence. 

Consumption  has  been  shown  to  be  a  distinctly  curable  disease  in 
the  sense  of  its  permanent  arrest.  It  is  known  that  a  large  proportion 
of  the  human  race  at  some  time  in  their  lives  imconsciously  harbor 
tuberculous  lesions,  and  that  complete  recovery  frequently  takes  place 
by  virtue  of  an  inherent  tendency  exhiliited  by  the  individual  toward 
an  encapsulation  of  the  tuberculous  process.  The  practical  effectiveness 
of  the  natural  constructive  forces  which  constitute  the  fundamental 
basis  of  any  successful  effort  toward  arrest  depends  very  largely  upon 
the  time  of  the  definite  recognition  of  the  disease  and  the  adoption  of 
rational  management,  an  early  diagnosis  usually  insuring  a  good  prog- 
nosis. While  strikingly  gratifying  results  may  sometimes  be  secured 
even  among  far-advanced  cases,  a  uniformly  successful  issue  may  be 
expected  only  in  the  incipient  stages.  Early  cases  of  tuberculous 
infection  are  of  vastly  greater  importance  than  those  of  the  advanced 
type,  by  virtue  of  the  more  favorable  ultimate  prognosis  and  the  avoid- 
ance of  an  indefinite  period  of  invalidism.  The  majority  of  consumptives 
•with  slight  involvement  may  justly  anticipate  an  arrest  of  the  t\ibercu- 
lous  process  and  a  more  or  less  complete  restoration  of  their  former 
health  and  vigor.  It  follows  that  the  direction  of  such  cases  is  vested 
234 


PREUMINARY    CONSIDERATIONS  235 

with  the  assumption  of  greater  responsibility  than  attaches  to  the 
management  of  desperate  patients,  for  whom  the  future  holds  but 
little  hope  of  restoration  to  their  former  activity  and  usefulness.  Thus, 
for  humanitarian  and  economic  reasons,  early  diagnosis  assumes  a 
position  in  the  general  consideration  of  consumption  of  infinitely  more 
momentous  consequence  than  any  other  phase  of  the  tuberculous  prob- 
lem. No  further  commentary  is  required  upon  the  fiequency  of  delayed 
diagnosis  than  my  repoi't,  a  few  years  ago,  of  an  analysis  of  1700  cases 
of  pulmonary  tuberculosis  observed  in  private  practice.  A  more 
heterogeneous  lot  of  consumptives  it  would  be  impossible  to  imagine. 
A  large  majority  of  the.se  were  of  an  advanced  type,  and  many  died 
shortly  after  arrival.  A  vast  number  were  in  greatly  impoverished 
circumstances.  Physical  signs  of  advanced  tuberculous  infection  were 
found  in  each  lung  in  69.1  per  cent,  of  the  cases,  while  in  53.05  per  cent, 
there  were  presented  unmistakable  symptoms  of  severe  systemic  dis- 
turbance, including  the  fever  of  mixed  infection,  emaciation,  weak  and 
rapid  pulse.  The  physical  signs  of  excavation,  in  addition  to  the 
above,  warranted  their  classification  as  advanced  cases.  From  a  critical 
analysis  of  the  history,  which  may  be  accepted  as  definitely  accurate, 
it  was  found  that  twenty  and  one-third  months  was  the  average  period 
of  delay  following  the  clinical  onset  before  arrival  in  Colorado. 

It  is,  indeed,  lamentable  that  thousands  of  lives  are  sacrificed 
annually  on  account  of  the  tardy  recognition  of  tuberculosis  and  the 
deferred  institution  of  energetic  management.  It  is  charitable  to 
believe  that  this  distressing  exhibition  has  been  occasioned  through 
inability  to  appreciate  the  significance  of  the  rational  symptoms,  to 
recognize  accurately  the  physical  signs,  and  to  interpret  properly  their 
import.  An  explanation  of  the  surprising  lack  of  familiarity  with  some 
of  the  considerations  pertaining  to  the  diagnosis  of  pulmonary  tubercu- 
losis is  found  in  a  superficial  knowledge  of  the  fundamental  principles 
of  practical  medicine.  ]\Iention  may  be  made  of  failure  to  elicit  essential 
historic  facts,  to  emphasize  and  group  rational  subjective  symptoms,  and 
to  observe  correct  methods  of  physical  exploration.  A  faulty  technic 
in  the  examination  of  the  chest  may  result  from  inadequate  training 
or  insufficient  care.  In  the  majority  of  cases  the  available  data  for  diag- 
nosis have  been  amply  sufficient  to  warrant  its  provisional  establishment 
long  before  the  medical  attendant  has  awakened  to  a  realization  of  his 
responsiliilities.  This  is  partly  explained  by  the  fact  that  many  cases 
of  consumption  exhiljit  a  slow  and  insidious  onset,  not  calculated  to 
inspire  apprehension  on  the  part  of  the  patient.  Frequently  the  symp- 
toms are  not  such  as  to  awaken  the  suspicion  of  the  physician,  and  the 
physical  examination,  if  made  at  all,  is  practised  in  so  superficial  a 
manner  as  to  preclude  ;i(Tiirato  i-csults.  In  many  cases  this  is  not 
conducted  until  a  provision.il  diuiiiiusis  is  apparent  from  the  constitu- 
tional symptoms.  At  liiui-s  the  onset  may  be  so  acute  in  character 
as  to  simulate  other  diseases,  and  obscure,  for  a  considerable  period, 
the  true  nature  of  the  affection. 

Perfect  accuracy  of  diagnosis  may  be  established  by  the  recog- 
nition of  the  tubercle  bacillus,  but  not  always  before  the  destruc- 
tive process  has  become  advanced  and  the  constitutional  disturb- 
ances pronounced.  The  physical  signs  occasionally  furnish  indubitable 
evidence  of  a  recent  active  infection  long  before  bacilli  appear  in 
the   sputum.     In   other   cases   the   history  and  subjective   symptoms 


236  DIAGNOSIS    AND    PROGNOSIS 

afford  provisional,  if  not  conclusive,  evidence  of  a  latent  concealed 
lesion  despite  the  absence  of  bacilli  and  of  well-defined  physical  signs. 
Early  diagnosis  is  a  matter  of  great  simplicity  when  bacilli  are 
demonstrable,  but  their  presence  in  the  sputum  is  dependent  upon  case- 
ation of  the  tuberculous  area  and  upon  their  evacuation  by  way  of  a 
small  bronchus.  Thus  it  happens  that  there  is  not  always  a  uniform 
relation  between  the  bacteriologic  evidences  and  the  physical  signs. 
It  is  not  unusual  to  discover  bacUli  when  no  physical  evidence  of  exist- 
ing tuberculous  involvement  can  be  obtained,  even  upon  the  most 
rigid  examination.  On  the  other  hand,  the  microorganisms  may  be 
exceedingly  scanty  or  absent  altogether,  when  an  apparent  activity  of 
the  disease  is  shown  by  the  physical  signs  and  general  subjective  symp- 
toms. Later  the  bacilli  may  become  decidedly  more  numerous,  not- 
withstanding a  pronounced  improvement  both  in  the  pulmonary  and 
in  the  general  conihtion.  I  have  under  my  care  at  the  present  time  a 
gentleman  who  Olustrates  such  possibility.  Upon  arrival  in  Colorado 
without  having  secured  improvement  during  six  months'  residence  in  a 
well-known  sanatorium,  he  exhibited  a  daily  temperature  elevation 
with  consitlerable  dyspnea  upon  exertion.  Examination  of  the  chest 
disclosed  the  presence  of  extensive  active  tuberculous  involvement  of 
each  lung.  Upon  the  right  side  the  affected  area  extended  from  the 
apex  to  the  fourth  rib  and  to  the  lower  edge  of  the  shoulder-blade;  on 
the  left  side,  from  the  apex  to  the  fifth  rib  in  front,  and  from  the  apex 
to  the  very  base  behind.  Throughout  these  regions  fine  and  medium- 
sized  moist  rales  were  easily  recognized  after  a  cough.  The  expectora- 
tion, amounting  to  about  two  ounces  in  twenty-four  hours,  con- 
tained very  few  Ijacilli.  The  patient  has  gained  forty  poimds  in 
weight,  presents  no  fever  at  any  hour  of  the  day,  coughs  but  little,  and 
has  comparatively  slight  expectoration.  There  is  marked  improve- 
ment in  the  general  health,  and  examination  of  the  chest  reveals  a  pro- 
nounced gain  in  the  tuberculous  process,  yet  the  bacilli  have  increased  to 
an  amazing  degree,  all  specimens  of  sputum  being  literally  "peppered." 


('H.\PTER   XXXYIII 

PROVISIONAL   DIAGNOSTIC  FACTORS 

Attention  is  directed  to  tlie  consideration  of  early  diagnostic  fea- 
tures, which  antedate,  in  some  cases,  the  appearance  of  bacilli  or  the 
recognition  of  well-defined  physical  signs.  These  factors  relate  to  the 
family  as  well  as  the  personal  history,  and  include  opportunities  for 
infection  and  the  influence  of  previous  diseases. 

FAMILY  HISTORY 

A  tuberculous  family  history  was  formerly  regarded  to  be  of  great 
diagnostic  significance,  but  its  importance  is  known  to  have  been  vastly 
exaggerated.  While  a  degree  of  clinical  interest  attaches  to  a  record 
of  tuberculosis  among  immediate  antecedents,  it  is  extremely  doubtful 


PROVISIONAL    DIAGNOSTIC    FACTOKS  237 

if  any  reliable  conclusions  can  be  adduced  as  to  the  greater  likelihood 
of  infection  by  virtue  of  hereditary  predisposition.  To  say  the  least, 
no  authentic  evidence  has  thus  far  been  presented  to  establish  an 
invariably  increased  susceptibility  to  the  disease  among  the  descend- 
ants of  individuals  eventually  succumbing  to  pulmonary  phthisis. 
Unfortunately,  as  a  result  of  the  misleading  import  of  an  excellent 
family  history,  many  a  consumptive  has  been  compelled  to  pay  the 
penalty  of  a  grossly  delayed  iliagnosis  with  the  chances  for  recovery 
greatly  reduced.  Others  in  perfect  health,  yet  with  knowledge  of  ante- 
cedent infection,  have  supposed  themselves  under  an  impending  shadow 
of  disease  and  endured  unceasing  apprehension. 

As  a  matter  of  diagnosis  per  se,  a  tuberculous  family  history  has 
but  slight,  if  any,  import,  though  in  some  cases  it  should  not  be  regarded 
as  altogether  valueless.  A  negative  family  history  is  unworthy  of  the 
slightest  consideration  in  an  effort  to  establish  a  diagnosis  in  the  midst 
of  obscure  conditions.  Per  contra,  a  positive  history,  unless  especially 
pronounced  and  extending  to  brothers  and  sisters,  should  not  unduly 
influence  a  diagnosis  otherwise  more  or  less  doubtful.  There  should  be 
the  same  unequivocal  interpretation  of  physical  signs  and  the  same 
diagnostic  significance  attached  to  subjective  symptoms  in  all  cases, 
regardless  of  the  fancied  influence  of  inherited  predisposition. 

ACQUIRED  PREDISPOSITION 

By  acquired  predisposition  is  meant  an  added  susceptibility  to  the 
disease  through  the  operation  of  certain  causes  w  liich  tliminish  individual 
resistance.  Among  these  are  included  overwork,  either  physical  or 
mental,  oppressive  cares  and  responsibilities,  sleepless  nights,  despon- 
dency, alcoholic  or  sexual  dissipation,  financial  reverses,  domestic 
infelicities,  social  excesses,  and  a  multitude  of  burdens  incident  to  our 
modern  civilization.  The  influence  of  these  several  features  of  every- 
day life  in  preparing  the  soil  for  a  non-resistant  reception  of  tubercle 
bacilli  is  too  thoroughly  recognized  to  warrant  elaboration.  Further- 
more, the  relation  of  these  component  factors  to  the  general  problem 
of  tuberculous  transmission  has  been  discussed  at  some  length  under 
Conditions  Influencing  Infection.  Their  practical  significance  from  the 
standpoint  of  diagnosis,  in  ca.ses  admitting  of  reasonable  doubt,  should 
ever  be  borne  in  mind.  It  is  apparent  that  a  thorough  investigation 
concerning  the  previous  environment  in  connection  with  associated 
facts  pertaining  to  the  history  may  furnish  information  of  decided  diag- 
nostic value. 

OPPORTUNITIES  FOR  INFECTION 

A  review  of  the  personal  history  should  include  a  scrupulous  search 
for  all  possible  sources  of  individual  infection.  This  necessitates  an 
inquiry  into  details  which  is  frequently  tedious,  but  nevertheless 
essential.  An  all-important  consideration  relates  to  the  intimacy  of 
contact,  if  any,  with  a  consumptive.  Upon  admission  of  such  associa- 
tion the  investigation  .should  proceed  concerning  the  time  that  this 
existed,  the  condition  of  the  patient,  the  final  termination,  and  the 
disposal  of  the  sputum.  In  many  instances  equal  significance  may 
be  attached  to  the  presence  of  phthisical  patients  in  workshops,  stores, 
and    offices,    as    in    the    family.     Surprising    difficulty   is    sometimes 


23S  DIAGNOSIS    AND    PROGNOSIS 

experienced  in  an  effort  to  elicit  information  of  a  reliable  character 
concerning  the  possibilities  of  infection  from  contact  with  infected 
invalids.  An  account  is  often  given  of  the  death  of  a  relative  from 
so-called  "bronchitis,"  "asthma,"  "pneumonia  which  did  not  clear," 
"chronic  pleurisy."  "general  debility,"  especially  in  the  aged,  "child- 
birth," etc.  A  careful  inquiry  will  frequently  disclose  the  history  of 
a  prolonged  illness,  characterized  by  pulmonary  hemorrhages,  fever, 
night-sweats,  progressive  emaciation  with  persisting  cough  and  expec- 
toration, thereby  revealing  the  true  nature  of  the  disease. 

The  existence  of  tuberculosis,  either  in  the  family  circle  or  within 
the  immediate  business  environment  of  the  incUvidual,  having  been 
demonstrated,  it  is  desirable  to  ascertain  regarding  the  intimacy  of 
association.  If  affecting  husband  or  wife,  sisters  or  brothers,  informa- 
tion should  be  secured  as  to  whether  or  not  the  two  occupied  the  same 
apartment  or  the  same  bed.  Often  it  is  found  that  one  was  engaged  in 
nursing  the  other,  and  confined  for  many  hours  by  day  and  night  within 
the  sick-room,  which,  perchance,  was  overheated  and  insufficiently 
ventilated.  The  duration  of  the  period  during  which  close  associa- 
tion took  place  possesses  considerable  interest.  If  prolonged  during 
several  months,  the  suspicion  of  an  acquired  infection  would  be  i-endered 
greater  than  if  for  a  relatively  short  time.  The  likelihood  of  contract- 
ing the  disease  varies  somewhat  according  to  the  condition  of  the 
patient.  Some  consumptives  with  incipient  or  moderate  involvement 
and  a  small  amount  of  tuberculous  sputum  constitute  but  a  slight 
element  of  danger  to  their  associates.  Others  with  advancing  exca- 
vation, excessive  expectoration,  and  marked  physical  exhaustion  inci- 
dent to  the  later  stages  represent  a  constant  source  of  peril  to  those 
about  them. 

By  far  the  greatest  importance  relates  to  the  information  acquired 
concerning  the  disposal  of  the  sputum.  This  factor  alone  measures 
to  a  great  extent  the  degree  of  clanger  attaching  to  the  presence  of  a 
pulmonary  invalid.  If  the  receptacles  for  expectoration  be  ordinary 
cuspidors,  handkerchiefs,  rags,  or  newspapers,  the  possibilities  of  infec- 
tion are,  indeed,  sufficiently  obvious.  Many  patients,  however,  imagine 
that  they  are  scrupulously  careful  in  this  matter,  although,  upon  inquiry, 
they  are  found  guilty  of  gross  hygienic  errors.  Very  recently  I  have 
questioned'  a  lady  of  the  utmost  refinement  who  protested  that  she 
observed  extraordinary  precautions  with  reference  to  the  sputum.  I 
soon  foimd  that  she  coughed  a  great  deal  in  the  night,  and  was  in  the 
habit  of  spreading  newspapers  upon  the  floor  at  the  side  of  the  bed  upon 
which  to  expectorate.  The  enormity  of  the  offense  was  intensified  by 
the  presence,  in  the  family,  of  a  year-old  baby. 

The  practical  consideration  regarding  the  sputum  relates  not  so 
much  to  its  chemic  disinfection  as  to  keeping  it  moist,  for  if  evaporation 
can  be  prevented,  the  danger  of  infection  is  reduced  to  a  minimum. 
Expectoration  into  shallow  cuspidors  with  small  apertiu-es  and  broad 
upper  surfaces  is  almost  as  bad  as,  if  not  worse  than,  upon  new.spapers, 
as  adherent  particles  of  sputum  are  frequently  allowed  to  remain  for  an 
entire  day.  The  small  sputum-cups  at  the  bedside,  even  though  con- 
taining water  or  strong  disinfecting  solutions,  are  notoriou.sly  inade- 
quate unless  covers  are  provided.  It  is  almost  impossible  for  the  bed- 
ridden consumptive  resorting  to  the  use  of  these  receptacles  to  deposit 
the  sputum  directly  into  the  solution,  as  inevitably  a  portion  will  cling 


PROVISIONAL    DIAGNOSTIC    FACTORS  239 

tenaciously  to  the  sides  of  the  cup.  The  drying  of  such  sputum  pro- 
ceeds with  the  utmost  rapidity,  and  results  in  an  element  of  veritable 
danger. 

In  the  exhaustion  and  sometimes  the  delirium  incident  to  the  last 
stages  the  possible  sources  of  infection  in  the  sick-room  are  greatly 
enhanced.  The  dangers  of  contamination  of  the  bed-clothes,  walls, 
and  carpets  are  exceedingly  great,  as  the  patient,  no  matter  how  care- 
fully instructed,  has  lost  to  a  degree  his  appreciation  of  individual 
responsibility. 

Thus  in  doubtful  cases  a  careful  investigation  relative  to  the  oppor- 
tunities for  infection  may  aid  in  the  establishment  of  at  least  provisional 
conclusions. 

PREVIOUS  DISEASES 

A  history  of  certain  diseases  prior  to  the  development  of  tuber- 
culous manifestations  is  possessed  of  undoubted  diagnostic  signi- 
ficance, both  in  children  and  adults.  A  severe  attack  of  measles, 
whooping-cough,  typhoid  fever,  pneumonia,  pleurisy,  or  influenza 
may  represent  the  first  signal  of  approaching  danger.  The  sj-mptoms 
of  pulmonary  infection  may  develop  shortly  after  the  subsidence  of  the 
acute  disorder,  or  only  after  prolonged  intervals,  when  the  restoration 
to  health  is  apparently  complete.  A  diagnosis  of  the  tuberculous 
nature  of  a  sthenic  pneumonia  may  be  made  in  some  cases  from  the 
tenth  to  the  fourteenth  day,  but  in  others  not  until  after  the  lapse  of 
several  weeks.  The  resolution,  though  slow,  may  appear  sufficiently 
progressive  to  disabuse  the  mind  of  the  clinician  concerning  the  possi- 
bility of  tuberculosis.  Sometimes  there  is  a  seeming  recovery  from 
the  initial  disease,  save  for  the  failure  of  the  patient  to  regain  a  full 
measure  .of  strength  and  vitality.  Frequently  no  suspicion  of  the  onset 
of  consumption  is  entertained,  the  pneumonia  being  supposed  to  fur- 
nish an  ample  explanation  for  the  impaired  general  condition.  In  a 
similar  manner  a  protracted  convalescence  from  typhoid  fever  or 
malaria  often  represents  the  period  of  early  tuberculous  manifestations. 
In  many  of  these  cases  the  tuberculous  infection  is  present  from  the 
very  beginning,  but  the  evidences  of  pulmonary  invasion  may  be  recog- 
nized only  after  a  considerable  interval.  I  have  observed  a  few  cases 
in  which  the  possibility  of  a  pure  tuberculous  infection  with  initial 
typhoidal  manifestations  could  be  completely  eliminated,  yet  after  a 
slow  and  tedious  convalescence  from  unquestionable  typhoid  the 
subjective  and  objective  evidences  of  tuberculosis  were  detected. 

The  history  of  an  idiopathic  pleurisy  with  or  without  effusion  is 
assuredly  a  factor  of  considerable  importance  in  cases  presenting 
symptoms  and  signs  of  doubtful  interpretation.  A  very  large  propor- 
tion of  idiopathic  pleurisies  are  known  to  be  tuberculous  in  character, 
irrespective  of  the  later  appearance  of  distinct  pulmonary  lesions. 
Sixty-seven  of  my  cases  out  of  a  total  of  2070  present  the  record  of 
a  previous  pleurisy.  The  history  of  pleurisy  without  assignable  cause 
should  suggest,  even  in  the  absence  of  well-defined  clinical  manifest- 
ations, at  least  a  strong  possibility  of  existinc;  i>\ilni()n;uy  tuberculosis. 

In  obscure  cases  the  history  of  influenza,  ritlui-  iiM-ent  or  remote, 
furnishes  still  another  landmark  pointing  towaid  a  lul.crrulous  process. 
The  relation  of  this  infection  to  the  subsequent  ile\elopinent  of  tubercu- 
losis has  been  chscussed  in  earlier  pages.     It  has  been  contended  by 


240  DIAGNOSIS    AND    PROGNOSIS 

some  that  the  onset  of  consumption  following  influenza  is  accounted 
for  largely  by  the  means  offered  for  the  more  extensive  distribution 
of  tubercle  bacilli.  This  hardly  appears  reasonable,  a  simpler  explana- 
tion being  found  in  the  increased  vulnerability  of  the  tissues  through 
the  influence  of  a  prevailing  epidemic,  in  connection  with  the  frequency 
of  latent  infections.  In  any  event  the  symptoms  of  consumption  have 
often  appeared  some  weeks  or  months  after  an  attack  of  influenza  in 
individuals  formerly  in  perfect  health.  The  previous  occurrence  of 
influenza,  therefore,  in  cases  admitting  of  considerable  doubt,  must  be 
accounted  a  factor  of  some  cUagno.^tic  importance. 

The  etiologic  significance  of  jiulmonary  hemorrhages  has  been  reviewed 
in  a  prececUng  section.  The  fact  that  aliout  20  per  cent,  of  all  piJmonary 
hemorrhages  appear  in  the  midst  of  apparent  health  as  the  first  symptom 
referable  to  tuberculosis  indicates  the  vast  importance  to  be  attached 
to  this  history  in  doubtful  cases.  As  previousl_y  asserted,  a  moderately 
severe  hemorrhage  maj'  take  place  in  the  entire  absence  of  subjective 
symptoms  or  of  physical  signs,  even  upon  rigid  physical  examination. 
While  the  history  of  a  remote  pulmonar}-  hemorrhage,  with  or  without 
occasional  recurrences,  does  not  j-ield  indisputable  testimony  as  to 
the  existence  of  a  possible  concealed  focus  of  tuberculous  infection,  the 
fact  remains  that  such  admission,  in  association  with  constitutional 
s}-mptoms,  even  of  a  doubtful  character,  must  be  regarded  as  strongly 
in  favor  of  pulmonary  tuberculosis.  In  each  instance  of  pulmonary 
hemorrhage  of  uncertain  origin,  however,  a  pronounced  effort  should 
be  made  to  determine  beyond  peradventure  the  absence  of  other  con- 
ditions capable  of  explaining  its  occurrence.  A  pro\-isional  conclusion 
as  to  the  tubercidous  significance  of  pulmonary  hemorrhage  can  be 
reached  only  by  a  careful  systematic  elimination  of  other  possible  etio- 
logic factors,  as  mitral  disease,  vicarious  menstruation,  purpura  hemor- 
rhagica, etc. 


CHAPTER  XXXIX 

PRESENT  CONDITION 

The  principal  diagnostic  features  relating  to  the  character  and  extent 
of  constitutional  disturbance  are  cough,  loss  of  weight,  fever,  and  accel- 
eration of  pulse.  These,  in  connection  with  the  physical  and  bacteriologic 
e\itlences,  usually  j-ield  information  of  an  imdovdjted  character. 

COUGH 

The  cough,  which  has  been  descrilied  at  length  imder  General 
Symptomatology,  is  often  the  first  subjective  manifestation  of  pul- 
monary tuberculosis.  It  is  more  frequently  present  than  any  other 
initial  symptom,  and  at  once  attracts  attention  to  some  involvement  of 
the  respiratory-  tract.  It  often  serves  a  useful  purpose  in  arousing  the 
early  apprehension  of  patient  and  friends,  and  is  of  signal  value  in 
exciting  the  suspicion  of  the  physician  as  to  a  possible  tuberculous 
invasion.  Upon  investigation  the  cough  may  be  found  to  be  occasioned 
by  catarrhal  bronchitis  or  laryngitis,  an  elongated  uvula,  or  a  follicu- 


I('licii(l('iit    upon  conditions   other 
lie  ali-ciicc  of   readily  explained 
ih  1(>^<  (il  weight  or  fever,  should 
1   a   IiiIhtcuIoiis  iiif(M-lioii,   (Icspitc 

al    M-iis.       .1     iiKiiilir,     ,xi>l<,r,ifinii 
■r  Ihr  hunirn  „,  proo/  rcluiy  upon 
inroln  IN,  III. 

is.  indeed,  a  variable  quantity.    It 
\y  may  lie  out  of  all  proportion  to 
nlc  d(•p(>^i1.     I'licrc  is  no  I'elation 

ir  nature  oi'  extenl  of  tlii'  lubercu- 
iperamenlal    idie-vneranes   of  the 

deieiiuiiunt;-  lactoi'  in  the  degree 
■i>nsi,-t  nieiel\-  (if  a  sliuht  clearing  of 
ly  (iriau'  in  se\'eiv  paroxysms,  with 

enll\    (.1   a  di-tiiirlly   nel\nus  type, 
■d    ]i\-  othel'  CMdenres  ul    hN'Steria. 
-ame  iiidixidual.  a.-Mudin-  to  the 
laeililie-    alTerded   tnv  mental  dis- 
li-i-  i-   iiMMv  likeix   1(1  (M-cin-  in  the 

he  l.alanceol  |iie('la\\    Hoarseness 
'  the  afternoon,  or  it  may  precede 

PRESENT    CONDITION  241 

lar  pharyngitis.  Wldle  frp(pie 
than  tuherculosis.  its  ]>ersi,^len( 
cause,  particidai'ly  in  comliinati 
be  construed  as  stroiml\-  imlica 
failure   to  elicit    chaiacleii  lie 

of  the  chrst  in  siirll  I'llsrs  ihirs  iiii, 
the  cnuiiiurr  irhn  ilmilils  ,i  tuim 
The  couiih  (if  incipient  tulieiv 
may  not  be  presenl  al  all.  or  its 
Other  manifest  at  ions  of  liciiinmn 
whatever  bet  ween  this  sNinptdn 
lous  process.  In  eaily'(aecs  tl 
patient  are  appaivntly  an  imp. 
andcharactei'dllhecduji.  Tlii- 
tiic  throat  at  intervals,  or  the  c(ii 
or  without  expectoration.  It  i- 
in  which  event  it  maj-  be  accdi 
It  is  subject  to  much  vaiiaiinn 
influence  of  external  caii.cs  am 
traction.  The  couuh  of  incipient  pliili 
early  mornim;  a  11(1  KmIi  appea  rdiirini:  t  li 
may  develop  during  I'.e  latter  jiarl   of 

all  other  sympnims.  and  from  its  persistence  afford  a  strong  suspicion 
of  an  un(.leilyiiig  tulierculous  infection.  The  ap]iearance  of  the  cords 
may  be  almost  normal,  or  there  may  be  tliickeiiiiiL;  and  reddening  from 
an  existing  catarrh  in  a;  (iciation  with  othei'  laryn.geal  clianges.  In 
very  early  stages  of  con:  r,m]ii  ion  the  (iia.miostic  value  of  cough  or 
hoarseness  consists  almo,  t  entir(ly  ol  the  siiui^cstiftn  offered  to  the 
examiner  of  po.s.sible  intrailidiacic  di ca-c.  If  the  cou.iih  does  no  more 
in  such  cases  than  to  emphasize  the  necessity  of  a  thoi'ough  chest 
examination,  and  a  judicial  inquiry  as  to  the  significance  of  accompany- 
ing symptoms,  this  surely  is  sufficient  to  establish  its  clinical  value. 

LOSS  OF  WEIGHT 

Loss  of  weight  has  loni;  l^een  regarded  as  one  of  the  cardinal  mani- 
festations of  consumption,  but  its  diagnostic  significance  in  incipient 
cases  appears  to  have  been  exag-ierafed  to  a  great  extent.  In  very 
early  cases  the  impairment  of  nutrition  is  but  trilling  or  absent  alto- 
gether. Sli.uhtly  later  in  the  disea-c  it  i  an  almost  invariable  accom- 
paniment of  other  s\'mp1omatic  (ii-tiirbanci>s.  and  is  then  iiiuhly  sug- 
gestiveof  tulieivuhw'i-.  .\-  a  -eiiei-al  rule,  patients  exhibitim;  decided 
emaciation  h.ave  heeii  .alHicte(l  l'oi-  ,a  lorn;-  time,  and  inamlest  other 
evidences  of  the  t  nberculous  mature  of  the  .alfectioii.  Cases  displaying 
pronounced  loss  ,,f  weight  c.aily  in  the  disease  are  necessarily  those  of 
acute  onset,  with  considerable  ele\-ation  if  lemperat  lire.  In  such  cases 
the  dia.gno.sis  is  not  made  upon  the  basis  of  the  dimini-hed  wei.uht,  but 
rather  by  virtue  of  the  accompan\inu  s\inptoms  .and  jihysical  signs. 
Even  without  cough,  exjiectoiatiou.  or  fe\-ei-.  if  combined  with  lo.ss  of 
strength,  shortness  of  breath,  and  a(a'eleration  of  pulse,  with  failure  of 
appetite  without  .satisfact(ii\-  explanation,  emaciation  strongly  empha- 
sizes the  need  of  exhaustive  jihysical  investi,gation  with  .r-i-ay  exami- 
nation and  the  employment,  in  occasional  instances,  of  the  tuberculin 
tests, 

16 


242  DIAGNOSIS    AND    PROGNOSIS 


FEVER 


The  importance  of  fever  is  perlnips  greater  tlian  tliat  of  any  other 
subjective  .symptom  during  the  early  stage  of  tuberculosis.  While 
its  absence  constitutes  no  argument  for  the  exclusion  of  a  positive 
tliaanosis,  its  ])resence  under  certain  conditions  is  assuredly  a  feature 
of  cxi-ciMliui:  iliauiidstic  value.  Statements  of  jjatients  regarding  the 
exisifiicc  of  ic\ci'  '.ivr  frequently  unreliable.  Many  experience  no  sen- 
sations (if  iiirrcascd  warmth  or  flushing  of  the  cheeks.  These  patients 
quite  invariably  deny  the  presence  of  fever,  which  is  rexealcd  only  by 
the  intelligent  "use  of  the  thermometer.  Almost  to  an  (M|ual  extent  is 
it  unsafe  to  place  dependence  upon  the  reports  of  in\alids  who.  with- 
out competent  instruction,  have  been  taking  their  own  temperature. 
Nothing  is  more  certain  regarding  the  fever  of  phthisis  than  its  extreme 
variability,  not  only  at  different  hours.  I.)ut  ujion  succeeding  days.  It 
is  clear  that  unless  the  t:'inii;M-aTui-c  i<  t:ikcn  fi-i-i  |iici!tly  and  systematic- 
ally, the  ai-i|inri"nirin  of  arcuraic  Liiow  Iri  L,'  roiiccrniiiL:  the  fever  record 
is  well-nigh  inipo<~ilil.'.  It  li  i-  I'Cfw  a  -oiim.  n\  (  \ ci-rccin-ring  surprise 
to  learn  in  many  individial  in-iaiici'-  that  ]ih\  .-.irians  were  content  to 
observe  the  temperatuiv  iiui  our-  i  da\'.  and  then  only  during  the 
morning  hours.  A  neuaUNc  icsult  oiim  atti-nds  several  observations  of 
the  tempeiatui'c  daily,  d—pitc  c. iii^i; leiaMc  intervening  elevations.  To 
obtain  approxiniaii'lN  coiiimi  intorniat  ion  tlie  thermometer  must  be 
used  in  suspcctrd  cases  at  inter\als  of  every  two  hours,  and  preferably 
during  a  period  of  several  weeks.  When  practicable,  the  temperature 
should  be  taken  by  some  person  other  than  the  patient,  and  a  careful 
record  maintainecl.  I  have  obser\'ed  many  invalids  who  have  been 
instructed  by  their  m-'diral  attendants  to  avoid  the  taldng  of  tem- 
peratures on  account  of  a  |Mis-il)le  md'ortunata  mental  influence.  Itisnot 
iineonuuon  tonote.  amoni;  iiiT\diis  jieople.  a  temlency  to  take  the  temper- 
attn-e  l"re(|nentl\\  witli  an  exi-,-.-i\-e  mental  |iei-tnrliation  following  even 
sliiihl  ele\alioii<.  In  e\e,.|,lional  in^tam-es  objr.et  i,,n<  to  |l,e  use'of  the 
tlKThioniet  -  may  l.e  .ii^lauied  alter  till'  diagnosis  has,, nee  lieeu  estab- 
lished. Kilt  iliiiinii  thi'  period  .iie;iri\-  observation,  in  doulitful  cases. its  use 
should  lie  in~i-ted  ii|ion.  iei:.ii( lle<-:  of  all  other  considerations.  Employ- 
ment of  I  hi-  theiiiionieier  re]iiesents  one  of  the  old-fashioned  principles 
of  ilia^no-i-.  the  rarefiil  and  | laiiKt.i kinu  apjilication  of  which,  in  recent 
yeai'^.  too  1  lei |iient ly  ha-  been  o\-,Tlooked.  Notwithstanding  irrecon- 
cilalile  dilferem  :•.-  in  the  \arious  makes  of  thermometers.  rea.sonably 
aiTiiiate  result-  ni,i\-  1  le  -eriired,  provided  the  instrument  is  retained 
in  'he  inoiitli  fill-  .1  ^illirieiit  time.  One-minute  or  two-minute  ther- 
monieteis  aie  often  e\ti-ein  'ly  unreliable.  Regardless  of  the  particular 
type  emploj-ed,  the  instrument  should  be  held  under  the  tongue  with 
the  lips  tightly  closed  for  not  less  than  five  minutes,  any  shorter  reten- 
tion being  practically  valueless.  As  a  general  rule,  the  temperature 
should  lie  ta';eu  indoors,  as  there  is  often  noted  in  cold  weather  a  differ- 
eini'  of  iVoni  one-half  a  degree  to  a  degree,  according  as  the  patient  is 
in  the  open  ail-  or  in  the  house.  I  have  found,  during  the  winter,  that 
patients  necessarily  housed  upon  stormy  days  exhibit  a  uniform 
elevation  of  temperature.  The  characteristics  of  tlie  temperature 
which  are  of  more  especial  importance  are  its  irregularity  and  atypical 
course,  its  usual  but  not  invariable  rise  in  the  evening,  and  the  exhibition 
of  an  average  for  the  day  slightly  above  normal.     Occasionally,  in  cases 


PRESENT    CONDITION  243 

with  very  incijiifiu  iiiffciidii,  ilic  tciii[)('i-;itiii('  is  slightly  elevated  after 
a  hearty  iiic:il.  iihy-iial  cxrnisc.  and  (hiiiiiu  periods  of  temporary 
excitemeiii .  IVxcr  in  sonic  cases  nia}-  lie  cxjiccted  to  attentl  the  time 
of  menstiiiatidn  and  tlic  cnsuiiii;  lew  days.  It  is  frequently  present  at 
noon,  onl\'  to  sid>siilc  tnward  evening,  or  it  maj'  be  absent  during 
almost  tlie  entiic  day.  and  rise  late  in  the  afternoon.  In  children  the 
range  of  tein])erature  is  usually  higher  than  in  adults,  though  not 
always.  At  tlie  othci'  e\t  renie  nf  life  the  fever  is  proportionately  lower 
antl  sometimes  alisi^ni  aliogetliei'.  in  sjiite  of  the  existence  of  an  active 

direct  suspicion  toward  a  tubercul.jus  in\  cil\  (  nieiit .  even  if  accompany- 
ing symptoms  are  exceedingly  indefinite. 

ACCELERATION   OF   THE  PULSE 

There  is  oftennocharaci  en-Ill-  change  in  the  pulse  during  the  incipient 
stage  of  consumption,  it  liein^  apparently  normal  in  very  many  cases. 
Sometimes,  howexcr.  clian^e-  nccm-  diiiini:  the  incipiencv  of  the  infec- 
tion, and  cvi  11  lielore  a  ,  leiiioiisl  r,-i,Me  l,acillar\-  sta-e.  'ilie  pulse  is. .lien 
of  low  ten-i.iii,  weak.  inilaMc,  or  rapid,      'facliyardia.  from    unkiM.wn 

heart  and  aorta  are  perhaps  of  small  size  in  such  cases,  as  stated  bv 
Brehmer,  <'linical  veiificatioii  is  seldom  pos.-iMe.  The  pulse  is  subject 
to  considerable  \ai'ialion  as  a  ivsult  of  coliipara  liwl  \'  trillin-  conditions, 
as  sli-lit  exertion,  aiun.aled  c.,n  v,T-ali.Mi ,  ,,r  oilier  caiis.-s  ot  nervous 
excitation.  A  bi.'tor  of  s„nie  iniporl.aiire  i-  ihe  iiTilabilitv  an.l  ac^-lera- 
tion  of  the  ]iulse  upon  cliaiiiic  of  ]  osilion.  all  lu.ii.i^li  at  rest  il  may  appear 
entirely  ncn-mal.  This  view  is  (lirectly  o])poscd  to  the  <ipinion  of  iliose 
who  maintain  that  the  characteristics  of  the  pulse  are  uninodilied  by 
change  of  ]iosition.  Acceleration  accompanying  pyrexia  is  of  less 
significance  than  that  which  results  from  emotional  excesses  suggesting 
nervous  cardiac  instability. 

EXPLORATION  OF  THE  CHEST 


The  results  ol 
disease,    usuallv   ( 

i  [ihysical  exami 

nation.  e\'en  in  the  inciiiiencv  of  the 

talice   all    other   features   ,.f  .lia-no-is. 
.n  ininiediately  upon  tliedexelol Tit 

in    adv.-inc.'   of   ll: 
of  the  Ihorax  i-  , 

:■;;;,''!;::;::;';;:;■,:,■ 

bacilli.     Unfortunately,  exploration 
1  il  a  provisional  diagnosis  has  become 

ignoi'ed    in    so    n 

It    to  i-iupli:i-i/,e  1 
nee   1<i   tlie   princ 

lie  nece^-it>- of  a  n i< ire  strict  and  con- 

iples  of   ph\-sical  diagnosis,  which  are 

.Mienti.ui'  should    a-ain    be    called: 

(1  1   ^"o  the  d('l;i  \' 
the  developineni 

in  in-i-tiiiL;  upon 
of  pronounced  c 

( Insi  iVu t'l .  i'l la l' 'a'n' d' '  I'.'i il'i 1 1'.  .'i i a  r\"  i n i p.-, i r- 

nient;  ('_>'    failure 
efie<-lii,-,nv    prev,- 

rot;ions  often   b.-i 
defined   tubercuh 
forced  ins])iratioi: 

nliii'^    an\-    ;ippi'i 
itire  .-he^l.  the  b: 

lus    inleclioii:    (  1 
1  in  eliciting  the  | 

iiot  withstanding  evidences   of   cleai'ly 
'   failure   to   (itilize   cough   preceding 
uvsence  of  moisture  in  the  finer  tubes. 

244  DIAGNOSIS    AND    PROGNOSIS 

The  physical  signs  of  the  ^•arious  stages  of  consumption  have  been 
described  in  the  preceding  section,  but  it  is,  perhaps,  well  to  review 
briefly  a  few  featiu-es  pertaining  to  cases  of  incipient  infection.  The 
attention  of  the  examiner  should  be  directed  to  a  possible  retraction 
at  the  apex  and  to  a  localized  retardation  of  respiratory  movements. 
Upon  palpation  he  should  carefully  note  the  existence  of  increased  vocal 
fremitus,  particularly  at  the  left  apex.  The  absence  of  slight  per- 
cussion dulness  must  not  be  misconstrued,  the  tuberculous  process  often 
being  capable  of  recognition  upon  auscultation  considerably  before 
the  evidences  of  consolidation  are  apparent.  Especial  attention  should 
be  given  to  outlining  the  boundaries  of  percussion  resonance  at  the 
apices  in  order  to  determine  the  shrinkage  from  infiltration  or  con- 
traction. Although  the  examiner  must  be  on  the  alert  to  recognize 
minor  changes  upon  auscultation,  e\-en  before  the  appearance  of 
moisture,  the  presence  of  unilateral  apical  rales  are  of  especial  signifi- 
cance, and  are  almost  ah\a>s  i)athognomonic  of  consumption.  Con- 
siderable importance  attin  hcs  to  <  lianges  in  the  spoken  and  whispered 
voice.  In  cases  of  sliuiit  intiltiatinn  the  spoken  voice  may  exhibit 
mereh'  an  iniTca-cd  intcn-iT\-  ni'  xnral  r.'SDiiaiir.',  but  with  a  greater 
degree  of  ciiii-MliilMiidii  diMiiirt  lii()iicli(i|ilii.iiy  i~  obtained.  An  ele- 
ment not  al\\:i>'s  appri'iiati'il  is  an  iiitaiisiticai inn  of  the  whispered 
voice.  This,  if  present  at  one  apex,  and  particularly  the  left,  suggests 
a  diminution  of  the  air-content  of  recent  or  remote  tulierculous  origin. 
The  presence  of  moist  rales,  percussion  dulness,  increased  fremitus, 
or  vocal  resonance,  with  unusual  intensification  of  the  whispered  voice, 
are  more  or  less  easy  of  recognition  in  comparison  with  the  finer  devia- 
tions from  normal  respiratory  sounds.  For  tire  detection  of  the  latter 
changes  the  utmost  concentration  of  the  mind,  added  to  a  somewhat 
extended  experience,  is  absolutely  essential.  It  is  customary  to 
describe  the  modifications  of  pitch,  intensity,  quality,  and  rhythm  of 
the  apical  rc<]>iiation  as  bronchovesicular.  It  is  difficult  to  conceive 
of  aii\-  dcviatidii  from  the  normal  vesicular  respiration  in  early  phthisis 
which  iIdi's  nut  entail  changes  conforming  to  this  type  of  breath- 
ing. In  the  event  of  very  slight  pathologic  change  involving  the 
mucosa  of  the  finer  tubes  there  may  he  noted  but  slight  modification  of 
the  normal  respiration.  The  vesicular  element  markedly  predominates 
over  the  bronchial  without  appreciable  abnormality  in  the  pitch, 
intensity,  or  dvu-ation  of  the  expiratory  sound.  The  change  from  the 
normal  may  relate  exclusively  to  the  inspiration,  and  partake  merely 
of  a  roughening  of  the  sound,  produced  by  the  thickened  mucosa,  which 
impedes  the  free  entrance  of  air.  This  may  represent  one  of  the  very 
first  auscultatory  signs  of  incipient  phthisis,  but  it  is  hard  to  imagine 
how  any  considerable  obstruction  of  the  lumen  can  exist  without 
likewise  interfering  with  expiration,  prolonging  its  sound,  and  raising 
the  pitch  to  some  extent.  The  inspiratory  sound  in  some  cases  may  be 
interrupted,  giving  rise  to  the  appellation  "cog-wheel"'  respiration,  but 
this  is  sometimes  recognized  among  the  non-tuberculous. 

As  has  been  explained,  modifications  of  the  respiratory  sounds 
discoverable  at  the  left  apex  are  possessed  of  much  greater  significance 
than  at  the  right  on  account  of  the  normal  disparity  between  the  two 
sides.  If  these  signs  are  detected  at  the  left  apex,  they  may  be  regarded 
as  pathognomonic  of  a  tuberculous  process.  The  presence  of  unilatei-al 
7-dle.t  at  either  apex  is  of  infinitely  greater  importance.     They  may  be 


PRESEXT    CONDITION  245 

present  in  the  morning  and  disuiipcur  in  the  uffernoon,  only  to  recur 
u]nm  the  following  day.  Iiulisiinct  and  iiKldiiiite  rales  may  assume 
greater  prominence  following  tho  tciuporai)'  adniiiiistration  of  potassium 
iodid. 

Through  the  detailed  application  of  the  principles  of  palpation, 
auscultation,  and  percussion,  irrespective  of  the  neA\er  and  special 
aids  to  diagnosis,  the  nature  of  the  tuberculous  process  may  be  recog- 
nized in  many  instances  prior  to  positive  bacteriologic  evidences. 

SPUTUM  EXAMINATIONS 

The  discovery  of  tubercle  l;>acilli  in  the  sputum  furnishes  the  most 
convincing  ))roof  as  to  the  true  nature  of  the  jniluiduai  y  afTcctidn,  While 
their  presence  may  be  regarded  as  c()nclusi\c  (■\i(l(iicc,  I  heir  non- 
recognition.  sa\-e  by  an  expert  after  I'epoatcd  cxainiiianiiiis.  does  not 
preclude   their  existence   in    fhespntuui.      'I'Im  ir  deindii-^l  I'aMe  absem-e 

dance  with  a  eareiul  technic  alfc.nls  no  abnilnte  inlurinal  i"ii  as  to 
the  non-tubennilous  charaiier  of  the  aflection.      Tlie   all    too   pre\alent 

of  thebacilbis  isa  praet  ice  cahailated  to  lelieve  the  plixsician  of  a  portion 

evasion  of  lii>  moral  ol  ilii^.-it'ioii  to  the  ]iatient.  Tlic  most  pi.rnicions 
feature  of  a  dia^no-  ,  ,  l,,un,le,l  exclir<ivelv  upon  the  discovery  of  bacilli, 
relates  t<.  the  nnnecessarv  dclav  Ix^lore  relne.lial  measures  are  a.i..pted. 
This  laxity  is  |■ran^llt  with  veiy  consideral  i|..  .lam^er  to  the  iii\ali.l, 
who.  restin.n  in  a  position  ol'  false  secui'ily,  |o-es  not  only  \-aln.able  lime, 
but  a  measure  of  opporlunihi  as  well,  in  the  stru^-li'  t<i  secure  aifest 
after  the  so-called  open  stage  of  tuberculosis  has  deNeloped.  it  is 
true  that  there  is  a  ceitain  burden  of  res]ionsiliilit y  imposed   up<iii  the 

in(M,ntr(iVertil.|e  bacillar\-  e\  ideii.-e  of  its  existence.  This  obtains 
parti. -ulaily  on  acc,,unt  ol  the  radical  advice  necessa.rily  -iveii  with 
reference  to  methods  of  li\-in,^.  suspension  ot  work,  change  of  occu- 
pation, severance  from  familw  am!  iccour-e  to  la\orali|i>  climates. 
On  account  of  the  involved  respoir-il  iilit  \-  ami  through  moti\cs  of  per- 
sonal interest  in  the  invalid  and  family,  the  chiuciaii  nui}  olteii  hesiiile 
to  pronounce  .sentence  without  the  coi-rob(]rali\c  e\i(lence  lurnished  by 
bacilli.  In  cases  in  whicii  the  combined  siibjeclixe  symptoms  and 
siu'us  are  stroni;I\-  suu'^est  i\'e  of  a  luberiailous  process,  there  can  be  no 
gre.-iler  dereliction  of  d'utv  on  tli,.  part  ,A  the  ph  vsiciam  t  lian  to  withhold 

tlie   (li.-L^noM-    until    the   appearance   of   bacilli.  '   (  »ii    tl ther  hand,  in 

tlie  absence  ol  clearh'  delilied  indical  ions  ol  tuberculous  llilection,  an 
un.|uali(ied  po-utiNV  decision  shouhl  not  be  rea.'lu.l  thron.nh  the 
uncertain  intiu-pret  .at  H  m  of  a  sinde  factor.  e\cn  thoui;h  possessed  of 
considerable  cliiiii-al  iiit(U'e<t.  .\iiioim'  tlio-c  who  are  A\)X  to  pride 
themse|\-es  upon  a  rellnement  of  di.'iiiiiosi^.  there  seems  to  be  a  growing 
tendency  to  aihoiate  iiiireserxcdh  the  remhuiiig  of  an  affirmative 
opinion 'r;(/;rr///  imlepcMideiit  of  the  bacilli.  In  the  iidfuvsls  of  the 
profession  and<if  huinanilx'  it  i~  lime  a  note  of  warning  w.as  sounded,  hir 
fear  lest,  in  the  midst  of  ult  ras.-ieulilic  entliusiasm  and  through  com- 
mendable pride  in  detailed  clinical  study,  the  swing  of  the  pendulum 
ma.y  eventuate  in  ill-sustained  notions,  causing  unnecessary  suffering  and 


246  DIAGNOSIS    AXD    PROGNOSIS 

embarrassment  to  the  supposed  pulmonary  invalid.  It  is  well  to 
maintain,  as  far  as  possible,  a  rational  and  moderate  attitude  with 
reference  to  the  discovery  of  bacilli  before  making  an  unqualified 
diagnosis  of  consumption.  Results  which  ultimately  are  to  be  satis- 
factorj'  to  the  patient,  relatives,  and  to  the  phy.sician  himself  will  be 
attained  only  through  a  careful  weighing  of  all  the  e\ideuces  presented 
and  ;i  jiuUi'ial  dctciininatidn  of  their  comliincd  import.  A  practical 
obji'itiiiii  111  witlilidldiii^  iii\ariably  the  dia,iiiic>>i-  until  the  recognition 
of  bacilli  aiiscs  iVdiii  the  tact  that  there  are  a  cniisKlcraljle  number  of 
physicians  \\li(),  ilnotmh  iiisiitficient  training  and  inadequate  teehnic, 
are  unaUe  to  detiMt  bacilli  tintil  the_y  are  present  in  large  numbers  and 
the  tlisease  ha.s  (•(.irrfspdiidingly  advanced.  Another  though  less  fre- 
quent source  of  error  relates  to  the  detection  of  supposed  tubercle 
bacilli  by  superficial  observers.  It  thus  appears  that  the  practical 
value  of  the  sputum  examination,  no  less  than  of  the  physical  explora- 
tion, depends  upmi  ihc  al>i!ity  and  training  of  the  examiner.  The 
selection  of  bancn  paiti<i(-  of  sputum,  the  making  of  a  thick  and 
uneven  smear.  (■aivl('-~ii(--  in  staining,  insufficient  decolorizing,  and 
haste  in  the  micrci>i()|iir  <iMrcli,  are  amoui;  the  ni(>i(^  common  causes  of 
mistaken  conclusions  iv;:aiiliim  the  iircsi-nrc  of  bai'illi.  The  manner 
of  examination  ]ii-c\iously  described  ma\-  be  inoilificd  by  comliining  the 
decolorization  and  tiie  counTci^-tainini;  .according,  to  the  method  of  Gab- 
bet.  After  the  iintial  stain  i^  washed  with  \\atei-.  this  consists  of  dry- 
ing the  cover-gla--  tor  a  tew  seconds  in  a  solution  eoniiiosed  of  "25  c.c. 
sulplniric  .acid.  11)11  I.e.  water,  and  _'  milli;;rams  methylene-blue.  follow- 
inii  which  the  '.ila--  i>  airain  washed  and  examined  after  drying.  The 
only  ad\aiiiaL:i'  -allied,  which  is  \eiy  slicht.  relates  to  the  shortening 
of  the  proce--.  hut  the  ie-iiltsare  not  quite  so  satisfactory  as  with  the 
metho.l  de-iiihe.l  m  ,iii  e.i  il  ier  chapter.  If  the  Kaiilli  are  found  to  be 
absent  alter  -e\ei.al  exaliiiliations.  more  conclilsi\e  results  may  be 
obtained  by  treating  the  sputum  with  a  solution  of  soda  or  potash  and 
centrifuging. 


CHAPTER  XL 

SPECIAL  AIDS  TO  DIAGNOSIS 

For  genera!  ]3iu-poses  the  diagnosis  can  lie  made  witli  sufficient 
acctirac\-  and  i-eleiiiy  w  itliimt  recourse  to  the  newer  methods  or  special 
aids.  Melay  h,i~  been  occasioned,  in  the  vast  majority  of  cases,  not 
throuiih  in.iliility  to  utilize  these  methods,  but  on  account  of  failure  to 
recoRiuzc  the  ample  sulijective  and  objective  clinical  data  already 
available.  There  are  many  difliciilties  in  the  way  of  establishing  an 
exact  and  early  diagnosis  thiouirli  the  agency  of  special  methods,  the 
necessary  restrictions  upon  their  employment  placing  them  beyond  the 
imineiliate  reach  of  the  general  practitioner.  The}'  may  be  regarded, 
howe\er,  as  of  value  in  very  exceptional  and  obscure  cases.  The 
newer  methods  of  diagnosis  of  special  importance  relate  to  the  use  of 
the  tuberculin  tests,  animal  experimentation,  and  the  Rontgen-rays. 


SPECIAL    AIDS    TO    DIAGNOSIS.  247 

THE  TUBERCULIN  TEST 

Save  under  very  puzzling  conditions,  recourse  to  the  old  tuberculin 
of  Koch  ])}•  subcutaneous  injection  is  quite  unnecessary  and  unwar- 
ranted. When  the  diagnosis  is  siithcii'iitly  clear  by  other  means,  the 
tuberculin  test  presents  no  addiiioiial  feature  of  value,  while  its 
employment,  unless  in  the  liands  n{  a  caicful  and  experienced  physician, 
is  vested  with  ceiiaiii  |Mis>iliilitics  (if  danger.  Shortly  after  its  intro- 
duction by  Kocii  II  \\a>  pidi  lainicd  by  several  students,  as  a  result 
of  considerable  icscaich  and  tinucal  observation,  that  the  tuberculin 
served  to  renew  I  he  .-iciiN  iiy  of  pre\i(iusly  latent  fnci,  and  to  disseminate 
a  general  tiihei-eulun-  infeciidn.  Kailically  difleiing  views  were  enter- 
tained by  palli(i|ii,L;i.-ts  a-,  to  lis  possiMe  inlluence,  at  a  time  when  it 
was  used  in  la.r.ncr  doses  than  in  i-ereiil  yeais.  It  may  be  assumed  at 
present  that  the  tubeiculin  in  carefully  ,iiiaduated  doses  in  the 
hands  of  a  skilled  cliniciaii  is  entirel\-  liariiiless,  the  only  danger 
resulting  from  its  indisciiniinate  and  (■■■ncle^s  adininist  lation.  In  like 
manner  the  possiliility  of  correci  conchi-ions  following  il<  u.-e  de])ends 
entirely  upon  a.  r\'/u\  a.dlierence  lo  cerlain  pivi'aiilionar\'  liieaMiivs, 
the  reaction,  if  present.  I>ein,-<if  niiK  h  or  .-li-lil  siniiillcaiice  arc.inliiiL:  lo 
the  confoi-niitv  of  its  eniplo\-nienl  to  ceHain  well-iveomiized  pnii(a|>les. 
The  production  <if  a  -eneial  reacli.m.  niark.'d  1  .y  lenipeiat  uiv  elevation 
and  more  or  less  coiistii  utmnal  disl  ui  b.-mce,  toi^elher  with  occasional 
local  manifestations,  coii>iiiuies  the  h.-isi-  ol  ihe  ie>i.  Some  op]iosition 
to  its  use  arises  from  the  e.xhibition  of  a  i)o>iti\e  reaction  in  cases 
apiiareiitl\-  not  tuberculous,  the  variable  degree  of  the  reaction,  and 
sometimes,  I  hough  rarely,  its  entire  al:)sence  in  infected  individuals. 
It  is  impoitant  to  note,  however,  that  when  the  reaction  has  occurred 
in  the  supposedly  non-tuberculous,  autopsy  lindinus  have  often  dis- 
closed the  presence  of  concealeil  foci  of  inaclixe  inlection.  While  this 
partly  accounts  for   its  exhiliition   ainom:  ap|)arently  healthy  people, 

the  very  fact  of  latent  tubercidosis  a ni;  a  lait;e  portion  of  the  race 

detracts  to  some  extent  from  the  sii;iiilicance  of  the  reaction  among 
individuals  suspected  of  early  pulmonary  lesions. 

The  occasional  absence  of  reaction  among  the  tuberculous  is 
ex])lained  largely  by  failure  of  less  practised  observers  to  conform  to  a 
strict  technic  in  the  manner  of  its  employment.  The  reaction  has  Ijeen 
founil  to  be  more  pi'onounced  in  recent  cases,  and  comp:ira1i\'el\'  slii^lit 

among   the   far   advanced,    the   increased    lolerance   a i;    lhi>    l.iliei' 

suggesting  an  effort  of  luiture  towaid  the  esiaMishnient  of  partial 
immunity.  It  is  po.sse.ssed  of  but  lilile  diai:noslic  siunilicance  if 
administered  in  the  presence  of  even  ^li^hi  ele\alions  of  temperature, 
a  fever  of  over  \)'.)°  F.  being  sufficient  in  many  cases  to  preclude  accurate 
cUagnostic  interpri'tations.  Inasmuch  as  ihe  |-eaclion  nia\-  be  allelided 
by  fever  raimiim  from  one  to  three  or  four  decree-  alHi\e  normal,  it 
is  readily  a]ipa rent  that  a  detailed  record  of  the  leinperatiire.  hir  several 
days  preceding  its  administration,  is  essential.  I'.efore  employing  the 
test  the  tem])erature  should  he  taken  at  not  less  than  two-hour  intervals 
during  a  jieriod  of  two  or  three  days,  pivhualily  a  week,  in  order  to 
avoid  any  confusion  arisinu  from  ordinal)'   lliicl  uat  ions. 

The  i-eaction  iisu;ill\  nccurs  m  the  nei^hlioi  hood  of  t  he  tenth  hour, 
but  may  be  delayed  until  the  second  day.  It  is  s<unetimes  accompanied 
by  symptoms  of  more  or  less  profound  constitutional  disturbance  of  one 


248  DIAGNOSIS    AND    PROGNOSIS 

or  twi)  (l;i\'s'  duration,  ponsistintr  of  fliill.  headacho,  pain  in  hack,  limlis, 

capal)le  of  recoi^uitiou.  iis  of  rnoir  smnilicainc  than  llic  iiciicial  distuili- 
ance.  While  the  local  manifest  a  lioii>  aiv  often  of  |ii-oiiouiieed  chaiarter 
in  tuberculous  involvement  of  the  Ixuies.  joints,  L;hiuds,  and  testicle, 
the  dclcciioii  of  definite  change  in  the  areas  of  pulmonary  infection  is 
not  alw  a\  s  |iM^.-;ible.  My  experience  with  the  ohl  tulierculin  for  diagnos- 
tic |iiir|i(i,-e,-  has  been  very  limited,  ha\iim  used  the  test  as  a  last  resort 
in  but  a  very  few  doubtful  cases.  Aniph'  oppdrtunity  has  been  afforded, 
however,  to  witness  marked  local  reaction  ioljowni.u  tiie  administra- 
tion of  the  bacilH  emulsion  for  therapt'utic  jiurpo.ses.  During  the 
past  year  this  aucui  has  Keen  ^i\cn  .■.xti'iided  emphiynient  in  .selected 
cases.  Thus  mean-  h.i\c  l>ccn  acipiiivd  lor  ;i  >t  U(l>-  of  the  hical  ivai'tion 
in  a  few  conspiciiou-  in-i:inccs.  In '■onncciicm  with  the  not  uncommon 
aggravation  of  con^ih  and  the  added  amount  of  e.\i>ectoialion  there  has 
been  found  in  sonir  in-i:inces  upon  auscultation  a  temporary  increase 
of  moisture  in  inUriid  at. -as.  With  the  bacilli  enuilMon  I  have  not 
lieen  able  to  detect  an  .ipj ireciable  modification  of  the  former  respira- 
toi\-  soiuids,  but  tills  is  reported  to  have  been  recognized  at  times  after 
injection  of  the  old  I  iiberculin. 

In  makiii'4  usi'  of  the  dlai:nostic  test  the  beginning  dose  should 
not  exceed  ,'„  of  a  inllll'.:rain,  although  some  clinicians  are  accus- 
tomed to  eiiiplo\-  Initial  dii~,~  of  two  or  three  milli2;rams.  There  is 
nothliL- part  Iciihnh' tub,,  l:;.  mrd  1  iv  adopt  In- the  lai-er  d.ise  in  the  be-in- 
mn-.  which  111  in.an'v  ,■;.---  iv-uli-  m  cMrciii..  di-v.,nnurt  to  the  patient 
and  pres,.|il-c,Tlai.M-l..|neiil.ul  danger.  1 1  I  h.. re  i~  no  react  ion  following 
its  initial  adiiniii-l  rat  ion,  a  Second  dose  may  be  iincii  after  tli(>  lajise 
of  several  da\s.  dining  which  time  the  temperature  should  be  recorded 
with  c.are  in  the  saine  manner  as  prior  to  the  fii<t  Injection.  In  case  of 
failure  to  react  after  smaller  iloses  they  ma\'  be  gradually  increased 
up  to  six  or  .seven  inillliirains.  It  is  not  .nhisablc  to  exceed  this  close 
in  any  event,  ami  \-er>-  rarely  jnstiliable  to  resort  to  over  two  or  three 
millliiiams.  The  only  objection  to  the  u.se  of  the  smaller  doses  is  the 
]io~~ib!i.  i-i:ili|ishmeiit  of  a  gradual  tolerance  on  the  part  of  the  system 
and  the  c()n-ei|iieiit  failure  to  secure  reaction.  .\n  intelligent  use  of 
the  tiibeiciilin  demaii.ls  the  exercise  of  tlie  utmost  c.-,ie  in  adjusting  the 
size  of  the  dose.  Till-  ari-i-  parllv  fnmi  the  n.^ce-Mlv  of  diluting  the 
crude  |iroduct.  It  is  well  to  make  the  dilnti(.n  at  the  time  of  its  admin- 
istraiidii.  as  ilie  product  becomes  inert  after  remaining  diluted  for  more 
than  inriy-iiiiht  hours,  although  some  continue  its  use  for  two  weeks 
after  ii  h.i~  been  prepared.  The  best  metliod  of  dilution  is  the  use  of 
O.o  |HT  ceiil  of  phenol  in  ,Iistille,l  water.  .Ml  the  .appliances  emploved 
in  Its  .adinini-lralion.  which  iiidud.'  the  -viw-r.  lubes,  pipet-.  etc., 
.Shonhl  1.,.  made  .ab-,,lutelv  sterile  bv  boiliil-,  precedm.Ll  each  injection. 
The  111(1-1  ii'.:id  ase]itii'  precautions  are  iiece-:<ar\-  to  avoid  the  unpleasant 
conse,|ueni-i-:  of  iufei'tion.  Those  who  niaki'  frequent  use  of  the 
ttlberiailiii  lur  iliauiiostic  ami  t  heralient  ic  purposes  are  found  to  favor 
v.aiioiis  -lie-  f(ir  the  point  of  injection,  but  it  is  extremely  doubtful  if 
tlii-  i-  of  special  moment.  It  is  usually  better  to  make  the  injection 
deeply  into  the  muscle  of  the  back  rather  than  subcutaneously.  The 
skin  should  be  thoroughly  cleansed  and  rendered  aseptic  with  alcohol 
or  ether.     A  sterile  pad  should  cover  the  point  of  injection  for  at  least 


SPECIAL    AIDS    TO    DIAGNOSIS  249 

twenty-four  hours.  Inhalations  of  tuberculin  for  diagnostic  purposes 
liy  me;in8  of  a  specially  devised  vaporizer  have  recently  been  employed, 
i)ut  the  results  thus  far  are  insufficient  to  justify  conclusions  other  than 
us  to  the  convenience  of  the  metlioil. 

While  the  legitima.tc  sidpr  uf  tiie  tuberculin  test,  when  employed 
subcutaneously  for  diaiiiidstic  ]>\irposes,  is  extremely  small,  and  its 
tiehl  of  usefulness  confined  cxclu-ixcly  to  a  few  doubtful  cases  otherwise 
iiicap^iMc  of  i>iccisc  dctciiiiinatioii,  it,  ni'\-(MtlK'less.  is  safe  to  conclude 
liiiii    iis  intclliiiciit   ciiiiiio^iiicnt    in  ihis  iiuinnci'  is  not  only  harmless, 

A  recent  iiiijxirtiiiil  i,i,»lijirali(ui  of  the  tuberculin  tost  has  been 
introduced  l.v  Caiiiiette  and  Wolff-Kisner.  known  as  il,e  ophthalmo- 
lulMirului  rnniinn.  I'.y  means  of  tliis  nietlKul  the  tuberculin  test 
rei)rescnts  a  most  \-aluai>le  aiti  t(i  diaiiiio^is.  and  it>  careful  employment 
seems   to   be   diveste.l   of   all    dl^a,ulveaMe   ur   ,  Imil'cious   features.      The 

diagnostic  purposes  is  f.ni'nd  m  the  |,,r;,l'  rea.'t  i..n"exlul.ited  bv  infect. hI 
individuals  folliiwin-  the  admnust  lal  i.m  of  the  tdxms  of  tlie  tubeivie 
bacillus.  This  .sciisitivenc>>  c,f  tlie  tisMies  was  n.Hed  |(,n-  a-o  follow  in- 
the  u.se  of  Koch's  old  tuberculin.  W  hil,'  |.m;,|  |e,M(.n-  were  bv  n.i  nieaus 
uniform,  the  frecjuencv  of  li\-pei'emia  an.l  .^wi'llini^  ai  the  site  ol'  injection 
was  iifti'U  the  subject' of  cc.niment.  .\|s,,  ni  animal  expeiameni  .a'l  i..n  it 
was  noted.  a>  staled  in  oilier  rliapteis.  lli.al  in  main'  iiiM.aiire-  an 
acquired  paitial  imimmilv  afler  pnmar\  iiio.ailat  ions  was  Me-eM,.|  bv 
the  more  intense  local  reaeli.m  .alleiidm,- t  he  .M'coiid  injections.  Uefeivncc 
is  made  in  the  chapter  upon  lmmiinit\-  to  the  ai'tion  of  the  toxic  sub- 
stances in  the  jiresein'e  of  llie  i  nl  lercuioiis  foia  of  infeiied  individuals. 
The  development  of  local  lemons  following  the  subcutaneous  emplo_y- 
ment  of  tubenulin  siiui:ested  u  response  of  the  tissue-cells  as  a  result 
of  the  absorptixe  products  from  the  foci  of  iidection. 

Th(>  (ir<t  prailic.il  .ipplication  of  these  piimaples  of  local  reaction  in 

ical  application  of  liiberciiliii  and  noleil  localized  swelliim-  and  congestion 
in  tuberculous  chihlren.  ( 'ainietle  siibse(pieiitl\-  utilized  the  same  princi- 
])les  by  ;ii)plying  tub(>rculin  to  the  conjunctiva.  By  the  use  of  95  per 
cent,  afcohol  he  precipitateil  the  tubeiculous  toxins  from  Koch's  old 
tuberculin.  After  dryini;  and  dilution  with  1  jicr  cent,  sterile  water  or 
normal  salt  solution,  one  dr<ip  was  instilled  into  the  e\'e.  In  finm  three 
to  eight  hours  this  was  loll, -wed  in  tuberculous  in.  li  vidiials  bv  a  |oc;il 
reaction,  varying  from  a.  s|iL;ht  redness  of  the  c-,ariinc|e  to  an  intense 
hvperemia  of  the  conjunctixa.  with  c<insi(lei.ib|e  secretion  and  at  times 
edema  of  the  lids.     The  reaction   rein.-iined    well    deliiied   for   three  ,,r 

tulKM-c'uloi'is  indi'vidii;il>  either'a  neuativc'  result  was  noted  or  efse  the 
reaction  w.as  mild  and  of  short  dur.alion.  The  fst  has  been  applied  bv 
a  c.Hisiderable  number  of  observei's,  who  li.ave  reported  in  the  main 
fairlv  uniform  results  c<ii'rol  ,,,rat  i\-e  of  the  conclusions  of  ("almi'tte. 
Bahlwiii  has  receiitlv  report..,!  his  ob,servati,.ns  .■,,n,-erniim  the  .■frM"i.;v 
of  this  test,  as  made  up.)U  V.',~  .-uses,  incliuliiui-  i\2  obs..rve,l  bv  Drs. 
Trembley,  Allen,  Twitchell,  Brown,  and  Hathbun.  X.-arly  all  the 
individuals  known  to  be  definitely  tubercuhius  ,lispla}-eil  a  positive 
reaction,  the  only  exceptions  being  a  case  of  miliary  tuberculosis,  a 
patient  being  treated  with  tulierculin,  and  a  doubtful  case  with  healed 


250  DIAGNOSIS    AXD    PROGNOSIS 

lesion  of  long  standing.  Of  the  doubtful  cases,  only  about  one-fourth 
responded  positively  to  the  test,  while  approximately  a  like  proportion 
of  apparenth'  healthy  persons  exhibited  a  definite  reaction.  Two 
strengths  of  a  filtered  sterile  normal  salt  solution  were  used,  and  a 
measured  drop  representing  0.025  c.c.  was  instilled  by  means  of  a 
throttled  eye-dropper.  The  solutions  were  sterilized  by  boiling 
after  being  sealed  in  small  glass  tubes.  A  0.5  per  cent,  solution  was 
employed  in  one  eye,  and  in  the  event  of  a  negative  reaction  a  drop  of 
a  1  per  cent,  solution  instilled  into  the  other  eye  after  a  lapse  of  forty- 
eight  hours.  The  reports  of  many  oliservers  indicate  that  the  reaction 
is  valuable,  but  not  entirely  infallible. 

Cohn  reports  that  eight  out  of  twelve  typhoid  patients  reacted 
positively  to  instillation  of  the  tuberculin.  His  own  observations  and 
the  experiments  upon  310  patients  tested  at  Fraenkel's  clinic  point  to 
the  value  of  a  positive  reaction  as  presumptive  evidence  of  tuberculosis. 
The  reaction  was  obtained  more  frequently  in  patients  in  the  early 
stages  of  tulierculosis  than  in  those  with  far-advanced  infection.  Thirty- 
eight  out  of  forty-one  patients  with  incipient  or  moderate  infection 
responded  to  the  test,  while  but  two  out  nf  furty-tive  in  the  later  stages 
displaj-ed  a  positive  reaction.  This  suuuc-t-  -iKuidy  that  a  negative 
respon.se  is  possessed  of  but  little  value.  WCli-tcr  and  Kilpatrick 
report  a  positive  reaction  in  all  indi\'iilu,iN  liaxiiiL;'  tuliercle  bacUli 
in  the  sputum,  and  com-ludc  that  tlic  ivaitidu  i^  nf  Imt  little  value  in 
the  doubtful  cases,  two  iiiili\  iduals  a|iparciiil\-  well  i li  playing  a  positive 
reaction.  Downes,  from  an  cxiieiieuce  with  twenty-four  cases,  is  led  to 
regard  the  test  us  of  idn^iilcialile  value,  as  does  Franke,  MacLennan, 
Mallan,  and  .\lessaii.|ii.  the  two  latter  being  inclined  to  attach  more 
importance  to  its  reliability  than  many  observers. 

My  own  experienee  witli  the  ophthalmotuberculin  test  has  been 
limited  in  its  apjiliration  to  forty-two  cases.  The  physical  and  bac- 
teriologic  findings  wei-e  clearly  unmistakable  in  twenty-seven  patients, 
the  tuberculin  reai'tion  lieiuu'  ]icisitive  in  every  instance.  The  diagnosis 
was  doubtful  in  fifteen  cases,  and  of  these,  four  responded  positively  to 
the  tuberculin  test,  while  ele\-eii  exliibited  no  rea<>tion  whatever.  Of 
the  latter  number,  the  family  hi-tur\  ,  dppni  i  imiiii-^  for  exposure,  previ- 
ous history,  and  subjective  sytnpidin-  -iii;L:(-te(|  >t  idniily  the  possibility 
of  a  tuberculous  infection  despite  neuatixe  i(-iilt<  of  physical  exami- 
nation. In  many  of  these  cases  a  pro\i<i(iiial  ilia^imsi-  ,ii'  tnliei'culosis 
had  previously  been  made.  Of  the  foui-  ddulittul  ca>e-  who  presented 
a  positive  reaction  to  the  nphthalmntulieiculiii  test,  a  delinite  diagnosis 
seemed  impo.s.sible  upon  the  l.a-i-  ni'  th.e  pli\~ical  sjuns  or  bacteriologic 
evidences.  Varying  degree-  of  react  inn  were  exhiMteil  among  the  twenty- 
seven  patients,  responding  i)()siti\'ely.  In  the  latter  cases  the  ^  per  cent. 
solutinu  of  ]>iecipitated  ttd^rculin  was  invariabl\  einploxed.  the  result- 
ing iuflainination  being  very  pronounced  in  fi^■e  in-tances  and  lasting  for 
several  days.  The  1  per  cent,  solution  wasuscil  only  uijon  patients  who 
did  not  react  to  the  initial  test.  A  drop  was  instilled  into  the  other  eye 
after  an  interval  of  two  days,  but  in  no  instance  was  a  reaction  noted 
upon  the  employment  of  the  stronger  solution.  An  interesting  feature 
was  the  delay  of  the  reaction  in  a  few  cases.  In  one  case  the  conjunc- 
tival inflammation  did  not  appear  imtil  after  the  lapse  of  thirty-six 
hours,  and  in  several  the  maximum  intensity  of  the  reaction  appeared 
not  until  after  eighteen  hours.     Fifteen  patients  submitting  to  the  oph- 


SPECIAL    AIDS    TO    DIAGNOSIS  251 

thalmotuberculin  test  had  been  subjected  for  variable  periods  to  small 
weekly  injections  of  bacilli  emulsion.  Of  these,  ten  exhibited  a  much 
slighter  reaction  than  those  not  subjected  to  tuberculin  therapy.  The 
test  was  not  employed  upon  any  individuals  who  were  presumably  well. 
Despite  the  comparatively  small  number  of  patients  to  whom  the  test 
was  applied,  the  results  thus  far  have  seemed  to  offer  abundant  evidence 
as  to  its  value  in  doulitful  cases. 

EXPERIMENTS   UPON   ANIMALS 

The  introduction  of  suspected  sputum  into  the  pt-iitdiical  cavity 
or  tissues  of  aniniuls  cdnstit  utes  a  special  means  <il'  diamio.-is  which 
in  the  past  has  been  cniplnyed  to  some  extent,  'i'lii,-^  is  aiteiided  with 
some  inconvenience  and  loss  of  time,  and  is  scai<'ely  piactii-al)le  in 
general  practice.  Further,  the  cases  are  exceeiliuiily  rare  which  (leinaiid 
ultimate  recour.se  to  this  method.  When  this  is  aitiiail\  true,  how- 
ever, it  may  happen  in  some  cases  that  a  ]ii('cisc  detei  iiiiuation  of 
the  condition  is  permitted  Ion.;;-  befoi-e  the  conclusion  of  the  animal  test. 
It  has  been  found  to  be  of  ureat  \alue  in  the  midst  of  obx-ure  non- 
progressive pulrnonaiy  conditions.  The  test  is  made  by  the  injection 
of  a  few  cubic  centuneier-  of  the  suspected  fluid  into  the  i^entoneal 
cavity  of  the  guinea -piu,  or  hy  the  iiit  nxhiciion  of  the  expectoration  u])f)n 
a  sterile  platiniun  loop  into  a  pocket  ]]ro(hiced  ]>y  the  sejiaration  of  the 
sidn  from  the  subcutaneous  tissue.  In  either  event  the  haii'  is  shaved 
from  a  small  area  siuroundiiiu  the  site  of  the  operation,  which  is  per- 
formed under  sfiict  antiseptii-  piiMaui  ions.  The  animal  killed  after 
six  or  eight  weeks  will  show,  in  jMisitiM'  cases,  pathologic  evidences  of  a 
tuberculous  infeciion.  The  unlorlunate  delay  in  securing  definite 
information  is  said  to  ha\c  been  o\-erconic  ici'enfl\-  1 1,\-  inject inu  suspected 
material  inlo  the  nialnluai'v  iilaiids  of  ,l:uuic:i-|  m.^-^  oi'  i-abluls  which  are 
suckling  their  \-oung.  I\\perinienl.-  | j<Mioi'ined  by  l.ariei',  INjnzoni, 
and  Hirschljorn  have  demonstrated  tlie  presence  of  the  bacilli  ;?i  loco 
after  a  delay  of  only  five  to  ten  days,  owing  to  the  favorable  medium 
afforded  for  growth. 

It  is  well  to  reiterate  that  tlie  idility  of  the  special  aids  to  diagnosis 
is  confined  to  relatively  few  cases,  and  that,  in  the  niajoiity  of  instances, 
the  available  evidence  is  anipl\-  suliicient  to  permit  a  iiositi\c  conclusion. 
The  u.se  of  some  of  the  newer  methods  dem.ands  a  compliiated  apparatus 
and  a  considerable  experience.  Tuberculin,  the  Koni-cn  ra\s.  and 
guinea-pigs  are  not  always  within  the  reach  of  the  iicneral  praciitioner, 
and  their  usefulness  ma>-  lie  s.ah'Iy  i'esei\cil  for  cases  excepti<inally 
obscure.  Other  special  nieihoiU  of  ili.-ii;no,-i~  ha\c  been  recommended 
from  time  to  time,  Init  iheir  use  r-  attended  with  nnich  variaf)ility  in 
results,  rendering  them  of  but  little  practical  value. 

THE  RONTGEN  RAYS 

The  hiijiinung  deposit  of  tubercle  is  not  alwajis  attended  with  suf- 
ficient consolidation  to  disclo.se,  in  the  radiograph,  evidence  of  struc- 
tural differences.  The  existence  of  an  ajiprecialile  deviation  from  the 
normal  shadow  presu))poses  an  antecedent  |iathologic  ch.ume  in  the 
pulmonary  tissues.  Provided  tlieic  is  im  unil.-iteral  localized  incivase 
of  density  observed  upon  transilluminaiii>n.  this  absence  of  asymmetric 
change  may  be  assumed  to  indicate  the  non-existence  of  any  gross 


252 


DIAGNOSIS    AND    PROGNOSIS 


tissue  abnormality.  On  the  other  hand,  a  structural  lesion  sufficient 
to  s)ww  a  distinct  shadow  change  is  often  preceded  by  such  sub- 
jective and  objective  signs  as  will  warrant  an  unqualified  diag- 
nos:is.     The  use  of  the  fluoroscope  is  admittedly  of  some  aid  in  afford- 


ira,  exerting  pro- 
f^iKns  suggesting  tuber- 
iilates  aortic  aneurysm. 


ing  an  opportunity  to  note  the  delaj-ed  or  diminished  descent  of  the 
diaphragm.  This" has  been  reported  l)y  several  as  characteristic  of 
the  very  incipient  stage  of  apical  involvement.  It  may  be  present, 
however,  in  cases  of  long-standing  pleural  adhesions  and  certain  abdomi- 
nal  conditions  interfering  with  the  movement  of  the  diaphragm.     In 


SPECIAL    AIDS    TO    DIAGNOSIS  253 

such  cases  this  sign  is,  of  course,  devoid  of  uiiy  si)eci;il  si<;nific:uice.  I 
have  observed  a  material  retardation  in  the  (icsccut  of  the  iliuphragm 
upon  one  side,  without  tlie  slightest  ohtainahh'  e\iilencc  of  tuberculous 
infection.  Some  have  reported,  as  a  result  of  transillumination,  a 
distinct  appreciation  of  the  comparatively  small  size  of  the  heart  in 


spite  of  normal  apical 

ndular.at  root  of  riKlit 

peculiar  conflguiation  of  ribs. 

consumptives.  While  this  is  of  clinical  interest  in  yielding  confirmatory 
evidence  of  previously  entertained  impressions,  such  recos;nition  per 
se  IS  insufReient  to  justify  an  assumption  as  to  the  existence  of  early 
tuberculosis.  In  the  same  way  it  may  be  added  that  while  wonderfully 
accurate  and  valuable  information  may  be  secured  as  to  the  extent  and 


254  DIAGNOSIS    AND    PROGNOSIS 

nature  of  tlio  strurtural  diaimv^  in  advanced  phthisis,  this  constitutes 
no  evidence  a-  in  tlic  nirarnihlr  utilit\-  (il  tlie  x-Tnv  for  diagnostic  pur- 
poses in  incipient  ca.^es  wilhdui  pioniiunced  lesions. 

One  of  the  chief  objections  to  the  use  of  the  Rontgen  rays  for  intra- 
thoracic lUagnosis  is  the  necessity  of  their  exclusive  employment  by 


Fig.  46. — Posterior  view.     Very  sliglit  tliiclcening  left  apex.      Moderate 
apex  witli  tuberculous  infiltration  extending  to  fourth  rib.    Note  tlie  peculiar  curve  of  ribs  in  upper 
part  of  picture.     Heart  small,  partially  obscured,  and  flisplaced  sliglitly  to  the  left. 

experts.  Only  in  such  hands  may  it  be  possible  to  secure  sufficient 
detailed  definition  to  permit  of  cfurect  interpretations.  In  an  effort 
to  obtain  the  necessary  detail  the  time  of  exposure  should  be  as  short 
as  possible,  and  the  chest  should  lie  at  rest. 


SPECIAL    AIDS    TO    DIAGNOSIS 


Fig  48. — Posterior  view.  Slight  tuberculous  infiltration  each  apex,  with  small  dis.seminated 
tuberculou.s  glands  in  the  cervical  and  upper  mediastinal  regions.  Arrow  indicates  isolated  remnants 
of  cervical  glands.    (For  fuller  description  of  this  case  see  p.  421.)    Heart  small  and  pulled  upward. 


256 


DIAGNOSIS    AND    PROGNOSIS 


During  the  past  year,  with  the  valued  assistance  of  Dr.  S.  B.  Childs, 
I  have  resorted  to  "radiography  in  a  large  number  of  clearly  defined 
cases  of  tuberculosis,  in  order  to  compare  the  clinical  and  skiagraphic 
findings.     This  method  of  cUagnosis  has  lieen  used  to  confirm,  if  possible, 


5r  view.     Well-defined  tuberculous  infiltration  at  the 
:  of  physical  siffns.  in  a  patient  exhibiting  progressive  1 
Heart  displaced  sliEhtly  to  the  right. 


the  results  of  physical  examination  with  reference  to  small  circum- 
scribed efTusions,  pulmonary  cavities,  and  suspected  mediastinal  glands. 
As  a  rule,  the  information  secured  has  been  strikingly  conclusive.  As 
a  result  of  this  intniiry.  however,  previous  convictions  as  to  the  .slight 


SPECIAL    AIDS    TO    DIAUA'OSIS 


Fig.  50.— Posterio 


.  —  on,  right  interscapular  ...,.„..,  ^„ 
3  clicks  at  end  of  in.>ipiration  following  : 


258 


DIAGNOSIS    AND    PROGNOSIS 


practical  value  of  the  x-ray  in  the  diagnosis  of  very  incipient  cases 
without  well-defij^ed  structural  lesions,  have  been  substantially  con- 
firmed. Though  transillumination  of  the  chest  has  not  been  found 
to  be  of  great  utility  for  the  purposes  of  early  diagnosis,  save  in  excep- 
tional cases,  it  has  afforded  in  some  advanced  stages  information  of  a 


highly  important  nature.     Decided  value  has  at 
ment  corroborative  of.   or  supplementary  to.   the   re- 
examination.    It  is  of  .some  interest  to  note  that  ~i  \t  r, 
but  undoubted  infection,  upon  the  basis  of  pliysical  m 
to  exhibit   no  appreciable  shadow  variation,     l^^j*  the  other  hand, 
although   the  physical  examination  in  some  iT;?it;ane^s  disclo.sed  signs 


its  employ- 
of  physical 
^os  of  .slight 
were  found 


SPECIAL    AIDS    TO    DIAGNOSIS 


259 


.  Fij;.  53.  .„ 
apical  mvolvemei 
case  is  of  interest 


'NoteTeenliTStf  H™"'^*'''^  tuberculous  infection  „f  tl,r  I,.ft  |„„g   witl.ouf 


or  view,      Extensi- 

mottling  in  scapul 

pare  with  Fie.W.plie^ms'""'""'  ~"" 


DIAGNOSIS    AND    PROGNOSIS 


of  an  exceedingly  definite  character,  apparently  permitting  conclusive 
interpretations,  the  radiograph  revealed  a  surprising  divergence  from 
the  clinical  findings.  The  lack  of  correspondence  between  the  results 
of  the  physical  and  z-ray  examinations  related  particularly  to  the 


deter 
puln., 


prlerate  tuberculous  infiltration  of  both  apices.  Cavity  size  of  egg 
Ki'iiing  of  mediastinal  pleura  extending  above  clavicles,  with  great- 

liiberculous  gland  at  junction  of  sixth  rib  with  vertebra,  as  indi- 
aitially  obscured,  and  displaced  upward. 

'\/.f  and  position  of  the  lioart,  the  diagnosis  of 
,1  the  .leteelioii  ol  l,roiM'l,ial  glands. 
'derate  canliac  ilisplaceiiieiit  from  the  traction 
le  iiroliferation  was  found  in  several  cases,  when 
I  suggested  upon  physical  examination.  This 
upward  displacement  resulting  from  marked 


SPECIAL    AIDS    TO    DIAGNOSIS 


261 


fibrosis  of  the  mediastinal  i)leiira.  It  is  well  understood  that  certain 
difficultif's  ill  the  \\a\-  nf  acciiiatc  physical  diagnosis  are  incident  to 
the  anaiduiic  Idcalimi  ni  a  coii-idcralilc  portion  of  the  heart  beneath 
and  to  the  right  of  the  sternum,  and  to  its  frequent  denudation  upon 


Fig.  56.— Posterii 
tissue  contractile  change.  Note  lieight  to 
with  left.  Slight  involvement  of  right  apex 
circumscribed  area  simulating  cavitv.  He: 
Compare  with  Fig.  102. 

the  left  side  by  pulmonary  shi 
of  cardiac  dulnoss  in  t\ilicicul(i 
Several  times  I  ha\c  cxpcricnci 
of  the  a--ray  in  dctcnniniim  wit 
dilated  or  hypertrophicd  oi'nan. 


:;-;■;'! 

'iy' 

ob>n' 

I'.'ed.'and    di 

iiS 

right. 

Th 

is 

often  increases 

the 

area 

'^^ 

Id 

t  ( 

liiru 

,■(■|■^•   mat 

MllfV     «it 

il   ex- 
it th( 

lent. 
■  aid 

nil 

!>(■ 

1\\c< 

I'll   a   (lis] 

liar 

cd  ai 

lid  a 

sta( 

■ie 

s  in 

the  way 

of 

a  cori'ect 

DIAGNOSIS    AND    PROGNOSIS 


pare  with  Fig.  169. 


\  i.w.  Pronounced  thickening  of  mediastinal  pleura,  with  infiltration  of  righl 
;  strongly  suggestive  of  pulmonary  cavity.  Second  and  tliird  ribs  on  the  riglit 
I  order  to  permit  collapse  of  cavity.     No  cavity  discoverable  in  picture.    Com- 


SPECIAL    AIDS    TO    DIAGNOSIS 


263 


differentiation  between  simple  ilisplaccnioni ,  :i 
and  changes  in  size  incident  to  udliricut  pciicauli 
are  enhanced  by  the  morl.iid  puhuuuaix-  <lianji( 
in  immediate  contiguity  to  the  heart  itself,  often 


isumptives, 
!icr  causes, 
ics   present 


of  percussion. 
of   inestiniabi 


In  such  cases  the  use  of  the 
\alue  as  an  aid  to  dia,i:n( 
necessary  for  the  accurate  study  of  the  licai 
the  cardiac  jjulsation,  there  is  lost  a  shar])  < 
short  exposures  of  from  one-half  to  one-fiftl 


has  l)eon  shown  to  be 
SIkhi  cxpiisures  are 
crwisc,  (111  account  of 
ion  of  outline.  \evy 
second,  however,  are 


264  DIAGNOSIS    AND    PROGNOSIS 

i-;ircl\-  attcnilccl  liy  satisfactory  results,  sa\e  in  little  children  or  much 
eniaciaii'il  adiilis,  I'ciicct  sliarinicss  n\'  outline  is  not  indispensable 
in  the  .Ictci-iuiuatiou  of  the  size  and  posiiiou  of  the  heart.  Moderately 
long  exposures  of  from  ti^•e  to  twenty  seconds  in  duration,  while  pro- 


Fig.  60. — Posterior  view.  W  ell-defined  tuberculous  infiltration,  both  apices,  more  marked  on 
the  left.  Pronounced  thickening,  mediastinal  pleura  and  peribronchial  infiltration.  Also  thicken- 
ing of  left  base.     Physical  signs  sliow  moisture  left  side,  apex  to  base. 

ducing  a  less  clear  definition  of  the  cardiac  lioundary.  are  occasionally 
required,  especially  in  well-nourished  individuals  and  in  tho.se  of 
considerable  muscular  development.  .\  hazy  outline  similar  to  tliat 
of  a  composite  photograph  is  sometimes  una\didaiile  in  skiatrraphs  of 


SPECIAL    AIDS    TO    DIAGNOSIS 


265 


the  heart  on  account  of  its  movement,  and  although  less  satisfying  from 
an  artistic  point  of  view,  is  none  the  less  valuable  in  a  study  of  the  size 
and  position.  The  position  of  the  heart  is  further  considered  in  con- 
nection with  displacement  of  organs  as  a  result  of  pleuritic  contraction 
change.     (See  p.  358.) 


Fig.  61. — Posterior  view.  Extensive  tuberculous  infiltration  of  botli  apices  on  tlie  riglit, 
ninth  rib,  and  on  ttie  left,  to  the  sixth.  Heart  small,  partially  obscured,  pulled  upward  a 
he  right.     Notice  higher  level  of  diaphragm  on  left  side. 


The  employment  of  the  x-ray  has  been  of  some  interest  in  the 
clinical  stuciy  of  pulmonary  excavation.  While  but  few  cavities  have 
appeared  in  the  skiagraphs  which  had  not  been  previously  detected, 
several  were  noted  by  the  physical  signs  which  subsequently  failed  to 


:ibb  DIAGNOSIS    AND    PROGNOSIS 

materialize  in  the  .r-ray  picture.  This  lack  of  verification  constituted 
a  conspicuous  feature  of  some  cases  in  which  a  diagnosis  of  pulmonary 
excavation  seemed  to  have  been  irrefutable.  In  each  case  error  in  the 
interpretation  of  the  physical  signs  was  occasioned  by  the  existence  of 


Fig.  62. — Posterior  view.  Extensive  tuberculous  infiltration,  right  lunc,  from  ._ 
base,  posteriorly.  .\s  result  of  well-defined  contractile  change  diaphragm  pulled  upward  i 
of  small  size  and  partially  obscured,  di.splaced  upward  and  to  right.  Tuberculous  infiltration  of  left 
lung,  from  apex  to  sixtli  rib,  posteriorly.  Note  mottling  in  both  lungs.  Cavity  left  upper  back. 
Compare  with  Fig.   101. 

a  localized  area  of  consolidation  directly  over  a  primary  bronchus. 
In  one  case  a  similar  diagnosis  of  pulmonary  cavity  had  been  made 
previously  by  three  clinicians  of  unu.sual  skill  in  conducting  physical 
examinations. 


SPECIAL    AIDS   TO    DIAGNOSIS 


267 


Bronchial  glands  were  depicted  prominently  in  a  few  pictures  after 
a  diagnosis  had  been  made  upon  the  basis  of  the  physical  signs  and 
pressure  symptoms.  More  frequently,  however,  they  were  found  in  the 
skiagraph  when  their  presence  had  not  been  unticijiated. 

Upon  the  other  hand,  the  .c-ray  picture  occasionally  simulated 
certain  pathologic  conditions  which,  in  fact,  did  not  exist,  notably 
aortic  aneurysm  and  pleural  effusion.  As  these  conditions  were 
assuredly  absent  upon  the  basis  of  the  physical  evidences,  it  follows  that 
the  slviagraphic  findings  per  se  are  sometimes  susceptible  of  erroneous 


Fig.  63. — Posterior  view.  Extensive  tuberculous  involvement,  entire  left  lung,  with  moderate 
infection  at  right  apex.  Pronounced  connective-tissue  contraction  change  in  left  lung,  with  marlced 
pleural  thickening.  Heart  small,  partially  obscured,  and  displaced  noticeably  to  the  left.  Small 
cavities  between  third  and  fourth  and  fifth  and  .sixth  ribs.     Compare  with  Fig.  97. 


construction  save  Ijv  an  expeif  iutc 

l-preter. 

was  occasioned  by  enormous  hxp 

ierll'..pliv 

the  simulation  of  pleural  effusidn. 

I.V  ex.vs 

tion  of  the  pleura..     .-Xs  a  result  n 

f    tllis   cnl 

a,'-ray  evidences  of  pulnidii^n  y  liihci 

rulosis,  t: 

that  valual)lp  supplementary  iiifd 

rinatidii   i 

cases  exliil.itiii-  definite  -iruVt  iiml 

chalice. 

diagnostic     sc(i|ie    is   limited    t(i   >iic 

U     rnwlU 

ber  of  inteie.-tiiiu  leptdchiiticiiis  ai 

■e  present 

position. 

the   .-li: 
ihasl.e 

iiK-al    and 
,.ii  I.Mved 

radid- 

raphv,  in 

most 

UHportant 

isideral 

>\o   num- 

to  illus 

trate  this 

268 


DIAGNOSIS    AND    PROGNOSIS 


It  is  worthy  of  note,  however,  that  in  a  few  exceptional  cases  the 
employment  of  the  x-ray  was  of  signal  advantage  as  an  aid  to  the  early 
diagnosis  when  the  physical  findings  admitted  of  reasonable  doubt. 

It   should  be  understood  that,  in  submitting  the  following  radio- 


Fig.  64. — Positerior  view.  Extensive  tuberculous  infiltration, 
■ation,  right  apex.  Well-defined  media-stinal  gland  at  root  of  right 
3scured.  and  displaced  to  left. 


graphs,  the  plates  are  selected  almost  entirely  with  reference  to  their 
relation  to  the  results  of  physical  examination.  It  is  designed  to 
pre.sent  the  .r-ray  findings  of  a  few  patients,  in  whom  the  diagnosis  was 
more  or  less  obscure,  upon  the  basis  of  the  phvsical  exploration  of  the 
chest.     In    addition,    there   are   exhibited    radiographs   of   individuals 


SPECIAL    AIDS    TO    DIAGNOSIS 


269 


displaying  well-defined  physical  evidences  of  active  and  extensive 
tuberculous  infection.  Tlie  patients  comprising  the  series  of  cases,  as 
represented  by  the  radiographs,  do  not  conform  to  any  fixed  type  of 
pulmonary  tuberculosis,  the  physical  signs  denoting  a  varying  degree 


placed 


Fig.  65.— Posterior  view.     Tuberculous  infiltration,  entire  left  lung,  with  pronouncei 
at  base.     Note  mottling  in  scapular  region.     Heart  small,  partially  obscured, 
t  infiltration,  root  of  right  lung.     Cavity  in  left  upper  bacli. 


Slighl 


and  character  of  pulmonary  invuh-puiont. 

x-ray  standpoint,  the  differftit  ]):ithi>liioic 

culosis,  from  the  veiy  incipiency  nf  the  (lis( 

The  pathologic   processes  shown 


IS  will  be  seen,  from  an 
;cs  in  ]uiliii"iiary  tulier- 
i  the  advaiiceil  .s'ta.ses. 
IV   examination   consist 


of  slight  apical  infiltration,  moderate  tuberculous  consolitlation,  localized 


270 


DIAGNOSIS    AND    PROGNOSIS 


in  extent,  wide-spread  areas  of  tuberculous  consolidation,  sometimes 
involving  an  entire  lung  and  parts  of  the  other,  differing  degrees  of 
pulmonary  excavation,  diffused  tubercle  deposit  in  miliary  tuberculosis, 


Fig.  66.— Posterior 
fibrous  tissue  change,  p 
by  the  lieart  over  the  li 
distributed  through  thi- 
ef vertebral  column,     i 


:  liii.c.witliwell-i 
iark  sliadow  occasione 
Well-marked  circumscribed  tuberculous  patchc 

:  of  right.     Xote  absence  of  heart  shadow  m  froc 

ipare  with  Fig.  98, 


well-marked  thickeningof  mediastinal  pleura,  often  simulating  aneurysm, 
tuberculous  enlargement  of  tracheobronchial  glands,  contractile  changes 
incident  to  fibrous  tissue  proliferation,  resulting  upward  and  lateral 
displacement  of  the  heart,  the  frequent  small  size  of  this  organ,  the 


SPECIAL    AIDS    TO    DIAGNOSIS 


271 


imperfect  descent  of  the  diaphragm  upon  one  side,  niarkeil  unilateral 
pleuritic  thickening  simulating  effusion,  small  an<l  niciderate  pleural 
effusions,  the  density  of  the  shadow  corresponding  with  the  curved 
lines  of  percussion  dulness,  localized  empyema,  pneumopyothorax, 
and  other  processes  of  a  non-tuberculous  nature,  though  of  diagnostic 
interest  in  connection  with  pulmonary  phthisis. 

The  DfcasiniKil  \itilitv  nf  t\w  .f-i-av  as  an  aid  to  the  early  diagnosis 
of  pulnidiiary  t  ul.civul.'isis  is  well  illustratod  in  Fig.  45,  which  shows 
a  pronouiii'cd  tulici'i-ulous  infilti'atioii  at  the  right  apex,  although  the 
apical  percussion  outline  is  entirely  normal,  as  shown  in  Fig.  6.     Careful 


Fig.  67. — Posterior  view, 
ig,  entire  left  lung.  Cavity 
orroborated  by  physical  signs 


tuberculous  infiltration,  witli 
front  of  the  spine  of  the  scapula  below  ; 
Heart  obscured,  but  pulled  to  the  left. 


auscultation  also  fails  to  disclose  the  slightest  evidence  of  tuberculous 
infection. 

In  connection  with  the  preceding  case,  the  radiograph,  Fig.  44,  is  of 
especial  interest.  In  this  insiaiii-c,  the  plivsiral  siiiiis  suu-^est  a  pdssible 
tubercle  deposit  at  the  ri^ln  :i|h'x.  Thei-o  is  an  anprcciablc  slii-in  kas-'C 
of  the  air-cdiitent  in  fliis  ri-i..ii.  a>  -Imwn  by  tlic  pci-ciis<i(.ii  b.iuiidai'ies 
represented  in  Vlis..  :','.  I'pcm  .c-ray  p.xaminatidii  there  i-  Inund  no 
evidence  nf  tubci-rje  deposit  at  eitlier  a])ex.  .\  thickming  c.f  the  right 
mediastinal  pleura  had  exerted  sufficient  traction  at  the  i-iglit  apex  to 
afford  a  reasonable  suspicion  of  shrinkage  from  tul)erculous  infection. 

In   the   radiograph,    Fig.  53,    is   shown   a   tuberculous    infiltration 


272 


;d  prognosis 


involving  almost  tlie  entire  left  lung.  While  the  auscultatory  evidences 
are  well  defineil  in  this  area,  there  is  also  an  appreciable  shrinkage  in 
the  percussion  boundaries  at  the  right  apex.  The  absence  of  shadow 
change  in  the  latter  region  is,  therefore,  possessed  of  considerable 
clinical  interest.  Upon  the  other  hand,  the  apical  shrinkage  seen  in 
Fig.  41  is  amply  explained  by  the  destructive  change  represented  in 
the  radiograph.  Fig.  .56. 

In  Fig.  4(i  the  skiagraph  discloses  clearly  the  presence  of  a  slight 
thickening  at  tlie  left  apex,  with  moderate  tuberculous  involvement  at 
the  right,  extending  nearly  to  the  fourth  rib,  yet  the  physical  signs  in 


Fig.  68.— Posterior  vii 
pleural  thickening  at  base, 
small,  obscured,  and  displaced  l 


ngin 
left. 


right  apex.     Hear 


this  case  are  entirely  negative.  The  small  size  of  the  heart  in  this  case 
is  worthy  of  note. 

By  reference  to  Fig.  47  it  will  be  seen  that  the  results  of  .r-ray 
examination  disclose  a  slight  tuberculous  process  at  each  apex,  some- 
what more  pronounced  upon  the  right,  with  an  appreciable  infiltration 
at  the  root  of  each  lung,  yet  in  this  case,  as  in  the  preceding,  the  physical 
signs  afford  no  sviggestion  of  tubercle  depo.sit. 

Fig.  49  is  also  of  nuich  interest  in  connection  with  the  early  diagnosis 
of  pulmonary  tuberculosis.  The  patient  had  displayed  for  several 
months  a  continuous  loss  of  weight.  There  were  daily  temperature 
elevations,  rapid  pulse,  and  general  prostration.     There  was  no  cough  or 


SPECIAL    AIDS    TO    DIAGNOSIS 


273 


expectoration,  and  the  physical  examination  was  absolutely  negative, 
yet  the  radiograph  shows  an  apparent  tuberculous  infiltration  at  the 
root  of  each  bronchus. 


In  Fig.  50  the  radiograph  represents  the  existence  of  a  localized 
tuberculous  infection  at  each  apex,  somewhat  more  pronounced  upon 
the  right  side.     The  physical  signs  in  this  case  at  the  time  of  examination 


274  DIAGNOSIS    AND    PROGNOSIS 

admitted  of  reasonable  doubt  in  their  interpretation,  although  some 
months  previously  moisture  was  recognized  at  each  apex. 

Evidence  of  shght  tuberculous  infiltration  at  each  apex  is  seen  by 


ugfresting  pleural  effusion,  in  corroboration  of  physical  sign; 


reference  to  the  radiograph.  Fig.  4S.  Tuberculous  cervical  glands  were 
readily  palpable.  Upon  each  side  there  was  pronounced  dulness  upon 
percussion,  and  the  respiratory  sounds  were  appreciably  enfeebled. 


SPECIAL    AIDS    TO    DIAGNOSIS  275 

The  results  of  x-ray  examination,  as  shown  in  Fig.  51,  are  strikingly 
corroborative  of  the  physical  signs.  In  the  radiograph  is  shown  a 
slight  tuberculous  deposit  in  the  right  middle  and  upper  back.     The 


physical  signs,  as  indicated  in  Fig.  .36,  relate  purely  to  the  presence  of 
very  fine  clicks  in  the  right  upper  interscapular  space  at  the  end  of 
inspiration  following  a  cough. 


276  DIAGNOSIS    AND    PROGNOSIS 

It  is  apparent,  from  the  preceding  cases,  that  the  x-ray  may 
occasionally  be  of  service  in  the  detection  of  small  localized  areas  of 
quiescent  or  arrested  tuberculous  infection.     This  is  especially  true 


Fig.  72,— Posterior  vi< 
upper  right  lung.  Large  ca 
left  lung.     Heart  obscured. 

when  an  incipient  tuberculous  process  limited  to  one  apex  is  unassociated 
with  fine  clicks  or  well-defined  modifications  of  the  normal  respiratory 
sounds. 

Among  the  cases  with  more  pronounced  tuberculmis  involvement 


SPECIAL    AIDS   TO    DIAGNOSIS  277 

there  was  no  difficulty  expericnciMl  in  cstnMi^hins  a  diagnosis  from  the 
physical  examination.  In  iiKin\  cases,  Imwcver,  the  information 
yielded  by  the  skiagraph  as  U>  tlic  extcni  and  nature  of  the  involvement 
was  of  considerable  value.     As  previously  stated,  this  related  especially 


to  the  detection  of  slight  degrees  of  cardiac  displacement  unrecognized 
upon  physical  examination. 

In  addition  to  the  cardiac  displacement  from  traction  exertedby 
virtue  of  fibrous  tissue  proliferation,  the  enormous  thickening  of  medias- 


DIAG^OSIS    AND    PROGNOSIS 


tinal  pleura  has  been  of  much  interest  in  many  cases.  The  lack  of 
])arallelism  between  the  physical  and  radiographic  findings,  with 
reference  to  pulmonary  cavities,  has  already  been  cited. 

The  frequency  of  the  conspicuous  enlargement  of  tracheobronchial 


Fig.  74. — Posterior  view.  Case  of  localized  empyema  of 
Skiagraph  taken  through  dressings,  showing  drainage-tube 
obscured.     Compare  with  Fig.  106. 

glands,  when  unsuspected  upon  physical  examination,  is  also  worthy  of 
note. 

In  addition  to  these  general  considerations,  to  which  attention  has 
been  called,  it  is  perhaps  well  to  analyze  a  few  features  in  some  detail. 

The  radiograph  discloses  the  existence  of  tuberculous  infiltration 
in  both  lungs  in  28  out  of  a  total  of  .37  ca.ses  of  pronounced  pulmonary 
infection.     In  9  instances   the   infection  of   the   lesser   involved    lung 


SPECIAL    AIDS    TO    DIAGNOSIS 


279 


was  not  noted  upon  physifal  examination,  although  the  more  extensive 
processes  in  the  other  were  leadily  detected.  In  these  cases  small 
areas  of  tuberculous  infiltratinn  are  shown  in  the  radiograph,  either  at 
the  apex  or  at  the  root  of  one  lung. 


Fig.  75. — Posterior  view.  Ca.se  of  old  pneumopyothorax  two  vears  after  Schede  i 
Cavity  injected  with  three  and  one-half  ounces  of  bismuth  solution.  Note  retraction  of 
and  unilateral  curvature  of  spine.     Heart  obscured.     Compare  with  Figs.  107,  108,  109. 


Among  the  non-tul)erculous  cases,  numliorinji-  10.  :•!  are  instances  of 
extensive  thickening  of  mediastinal  pleura,  nf  which  th(>  radiograph 
in  1  case  sinuilated  the  appearance  of  aneurysm  to  a  striking  de- 
gree.    One  shows  clearly  the  characteristic  letter  "  S  "  curve  in  pleural 


280 


DIAGXOSIS    AND    PROGXOSIS 


effusion,  2  are  cases  of  circumscribed  pneumothorax,  2  of  pneumopyo- 
thorax,  1  represents  the  pathologic  change  in  carcinoma  of  the  medias- 
tinum and  lung,  and  1,  in  abscess  of  right  lung  following  pneumonia. 


In  the  distinctly  tuberculous  cases  the  mediastinal  pleura  is  greatly 
thickened  in  19,  the  simulation  of  aneurysm  being  pronounced  in  5.  In 
the  radiographs  taken  from  cases  of  carcinoma  of  the  mediastinal  pleura 
and  abscess  of  the  lung  respectively,  the  resemblance  to  aneurysm  is 
especially  marked. 


SPECIAL    AIDS   TO    DIAGNOSIS 


Extensive  unilateral  thickening  of  the  pleura  is  found  in  18  instances. 
Of  these,  the  possibility  of  pleural  effusion  is  suggested  by  the  radio- 
graphic findings  in  8  cases. 

A  pronounced  disparity  with  reference  to  the  height  of  the  diaphragm 
upon  the  two  sides  is  noted  in  8  cases. 


Fig.  77. — Po.sterior  view.  Case  of  circumscribed  empyema  1 
ing  resection  of  tentli  rib.  Small  dark  spot  in  riglit  base  is  tlie  siiadow  of  a 
the  middle  of  tlie  cicatrix.  Slight  infiltration,  upper  portion  of  each  lunj 
at  the  right.  Thickening  of  mediastinal  pleura.  Pulling  of  heart  upward  i 
of  small  size.     Compare  with  Fig.  105. 


specially  pronounced 
■     1  the  right.    Heart 


The  heart  is  apparently  of  small  size  in  20  instances.  It  is  partially 
or  entirely  obscured  in  17,  while  in  the  remaining  cases  no  deviation 
from  the  normal  size  is  suggested.  As  a  result  of  the  traction  incident 
to  fibrous  tissue  change  the  heart  is  tlisplaced  to  the  right  in  9  cases, 


^»^  DIAOXOSIS    AND    PROGNOSIS 

to  the  left  in  10.  upward  in  6.  upward  and  to  the  right  in  5.  upward 
and  to  the  left  in  1,  making  a  total  of  31  instances  of  cardiac  tlisplace- 
meut. 


Slight  tuberculous  infiltration  of  right  upper  lung. ' 
i  pleural  thickening  at  right  base.     Compare  with  Fi( 


Pulmonary  cavities  are  shown  in  13  cases,  and  perceptible  enlarge- 
ment of  tracheobronchial  glands  in  10. 


SPECIAL    AIDS   TO   DIAGNOSIS 


283 


Fig.  79.— Posterior  vi( 
pleural  thickening  at  base.     Note  the  lateral  s 
change.^.      Moderate  tuberculou.s  infiltration, 
obscured,  and  displaced  to  the  left.     Compare 


re  left  lung,  with  marked 
fibrous  tissue  contractile 
Heart  of  small  size,  partially 


DIAGNOSIS    AND    PROGNOSIS 


Fig.  80.— Posterior  view.  SliEht  flii 
tuberculous  involvement.  Sliclit  luoltlinj 
infection.  Well-defined  pleural  tliickenini 
placed  slightly  to  the  right. 


SPECIAL    AIDS   TO    DIAGNOSIS 


„.  -tf,  ^'av  w?°Bif" ?!^  ^"'J^i  Moderate  tuberculous  infiltration,  right  apex.witli  a  small  and  arge 
cavity  Slight  infiltration  eft  apex.  Thickening  at  roof  of  left  lung.  Heart  of  small  size.  Well- 
marked  thickening  of  mediastinal  pleura  simulating  aneurysm. 


CD    PRtKiNOSIS 


Fig.  83.— Posterior  view, 
pleura,  simulating  aneurysm. 
root  of  both  lungs.    Heart  displi 


Gross  infiltration  at  right  apex,  with  thickening  of  mediastinal 
Slight  tuberculous  opacity  at  left  apex,  with  some  thickening  at 
iced  a  little  to  the  right.  Partial  obliteration  of  cavity  at  right  apex. 


SPECIAL    AIDS    TO    DIAGI> 


rked  fibrosis  of  mediastinal  pleura,  simuliiluig  aiuui>.>iii. 
.  and  below  clavicle,  inclosed  by  fibrous  tissue  band  wliicb 
IS  disclosed  by  the  fluoroscope.  Heart  small,  partially 
eft.     A  complete  cervical  rib  on  right,  rudimentary  on  left 


DIAGNOSIS    AND    PROGNOSIS 


Fi^.  S'). — Posterior  view.  Infiltration  of  each  apex.  Well-defined  ttiiclceninff,  mediastinal 
pleura,  markedly  simulating  aneuo'sm.  Large  circular  pulmonary'  cavity  in  right  upper  region, 
t'harartpristic  mottling  from  tuberculous  infiltratioa  on  both  sides.     Heart  small  and  displaced 


SPECIAL    AIDS    TO    DIAGNOSIS 


Fig.  86.— Posterior  view.  Extensive  < 
simulating  aneurysm.  Diffused  glandular  involvement  in  both  I 
ment  of  the  left  breast,  which  was  completely  excised  two  y 
infiltration  in  the  lung  are  corroborative  of  physical  signs.  A 
per  pliotograph  (  Fig.  25),  over  the  upper  part  of  the  .sternum, 
and  to  the  right. 


rs  ago.  Evidences  of  advanced 
ible  palpable  mass,  recognized  as 
leart  obscured,  displaced  upward 


DIAGNOSIS    AND    PROGNOSIS 


Fii:  *^7  r.>-i.-iii.r  \  i.w  .  Skiagrapli  taken  after  death  from  general  miliary-  tuberculosis  compli- 
cating pulmonary  phthisis.  Extensive  tuberculous  infiltration  with  pleural  thickening  of  left  side. 
Heart  small,  obscured,  pulled  materially  to  left.  This  picture  is  of  especial  interest  as  showing 
well-defined  miliary  deposit  in  right  lung,  unobscured  by  thickened  pleura. 


SPECIAL    AIDS   TO    DIAGNOSIS 


291 


fHF 


Fie.  88. — Posterior  view.  Pronounced  fibi 
marked  displacement  of  heart  to  right.  Slight  ( 
ity.  best  marked  between  sixth  and  seventh  rib.s. 
condition  is  more  fully  described  in  text,  see  p.  2£ 


>us  tissue  proliferation  of  right  lung,  produc'ng 
?struction  of  pulmonarv  tissue,  as  shown  by  cav- 
Moderate  infiltration  at  root  of  left  lung.  (This 
1.)     Heart  of  small  size. 


DIAGNOSIS    AND    PROGNOSIS 


terior  view.  Thickening  of  medias^tJiial  pleura,  w 
in  right  upper  lung.  Two  well-marked  glands  at 
St  by  virtue  of  anomalous  shadows  upon  eacli  side, 
by  x-ray  appearance.    Heart  of  small  size. 


dislocated  upward. 

ght  bronchus.     This 

apable  of  interpretation  by 


SPECIAL    AIDS    TO    DIAGNOSIS 


293 


Fig.  90.— Anteric 
shadow  very  closely  .*i 
confirmed  by  autop.sy 


Bw.  Large  abscess  in  right  lung,  following  pneumonia.  Cir 
ating  aneurysm,  and  blending  with  the  shadow  of  tlie  heart, 
jrtesy  of  Dr.  Sewall). 


DIAGNOSIS    AND    PROGNOSIS 


CHAPTER  XLI 
DIFFERENTIAL  DIAGNOSIS 


The  clinical  manifestations  of  a  few  chronic  non-tuberculous  pul- 
monary conditions  closely  simulate  those  of  consumption.  While  a 
provisional  dia.snosis  may  be  made  from  the  histoi'v,  occupation, 
clinical  course,  and  ))liysi(Ml  sii;ii>.  in  many  iiisiaiiccs.  a  definite  differ- 
entiation from  piiliiiuiiary  tulicrculci^i-  is  n-iidi'iid  pd-sihle  only  by 
exhaustive  sputum  r\aiiiiiiaii(in>.  and,  in  a  lew  ca.^os,  tlirough  recour.se 
to  the  newer  methods  of  diai;nosis.  Occasionally  even  the  presence 
of  bacilli  does  not  alToi-d  accuiate  information  as  to  the  precise 
nature  of  the  patlio|o'.iii-  (■liaiii;c.  'I'his  is  particularly  true  of  the 
so-called  "niinci's  phi  hi^i^.  '  dilliculf  of  disassociatiou  from  consump- 
tion, yet  (hlTcrili'^  \\idi'l\'  iii  the  chararlcr  ol'  the  nioi'liid  conditions. 
The  appoaram-c  ol'  l.a(alli  onl>'  atlci'  Iouli-i-oiii  iiiihmI  oI)sci'\  ation  does  not 
justif\-  the  a,~siiiii|ilioiL  of  tiilM'i'cii|o~i~  as  a  faclor  nf  ,■!  lojo-ic  importance. 
The  tcianiiia!  iiifrci  10,1  1-  iii,.|f|y  m^raft.'d  upon  a  -.,ii  prc\iousl>-  made 
receptive  Ijy  viituc  of  marked  patholo-ic  ihaimc.  Aliiici's  phthisis 
consists  of  an  interact  i\c  comliiuation  of  cliidiiic  I  ironchit  is.  cnipliy.sema, 
and  pneumonokoniosis  iu  comicction  with  frccpicnt  bionchiectases 
and  circniatorv  distui  liariccs.  Thi-  sxinpioms  and  i;cncial  course  are 
described  cNcwIiciv.  In  lliis  connection  ii  is  sulli(aent  to  state  that 
the  clinical  manifol.al  ions  are  \-ery  .-uiiLiesI  i\-e  of  tuliei-culosis,  especially 
the  cou^ili,  expectoiation,  ily-piiea,  and  the  occasional  hemorrhages. 
There  is  raivl\-.  ho\\e\-ei'.  an\  e|e\,iiion  of  temperature.  The  c_yanosis 
is  quite  di-pinpoi  tionate  lo  the  pli\--ical  evidences  of  pulmonary 
involvement.  The  dyspnea  ra]jidl\-  increases  \intil  it  is  noticeable  even 
upon  the  slightest  exertion.  The  couuli  i-  H-iiall\'  patow-mal,  and 
the  sputum  frothy  and  light.  The  ])li>-ical  -i'jii<  which  are  described 
in  ooimectjon  with  pneumonokoinosis  do  tiot  ijilfer  materially  from 
those  di-].|ayed  l.v  nianv  cas.-s  of  pultiM.narv  t  ul  .efculosis.  "'  WhUe 
often  there  aiv  liilatei'ai  e\  idences  of  cat  ;i  lalial  liud|\-enient  and  emphy- 
sema,, ph\~ical  examiiialion  -(iineliine-  di-dose-  signs  of  unilateral 
I  ciic-um-ciihed  aiva-  ol'  ni..i-tiiic  and  not  infrequently 
I's.  The  hi-toiy.  occupaiion.  alisence  of  fever,  dis- 
piie.a.  and  c\aiiosis,  the  parow-m.al  character  of  the 
cut  ,-epaiation  of  the  spvitiim  into  distinct  layers, 
liihiteial  -iLins  of  catarrhal  dist  ni  l.,iiice  ami  the  coexist- 
iith  colli  iimed  negative  bacteiiologic  lindings,  suggest 
-tiiberciiloiis  chaiacter  of  the  condition,  despite  the 
loiihage  and  the  occasional  unilateral  involvement. 
little  excuse  for  confounding  pulmonary  tuberculosis 
iiiic  bronchitis,  bronchiectasis,  uncomplicateil  emphy- 
iiitei-stilial  pneumonia.  The  fact,  howc\-ef.  that  this 
is  in  connection  with  varying  degrees  of  [jneunionoko- 
nio-i-  as  fiv.piently  obsi.|\ci|  in  miniiit:  icuions,  with  or  without  cavity 
formation,  con-iitutes  .a  \'ei\-  iniisidei  .aMe  proportion  of  all  cases  of 
chronic  uon-tuberculoiis  pulmonary  affections,  affords  ample  opportunity 
for  errors  in  diagnosis.  This  grouping  of  conditions  is  more  or  less 
frequent  in  parts  of  Colorado,  and  is  often  confused  with  tuberculosis. 


con- 

-oli.l.ation.  \ 

pulr 
pro] 

COUi 

di,    tile    fre 

toge 

thei'  with  tl 

ing  1 
the 

L^mphyseni: 
essential   n 

occurrence  of  1 
There  can  be  1. 

with 

1  actite  or  c 

seni: 

a,  or  chroii 

groi; 

ipof  COlldlt 

DIFFERENTIAL    DIAGNOSIS  295 

Other  non-tuberculous  ailments  are  found  to  present  an  apparent 
similarity  to  consumption. 

The  existence  of  chronic  influenza  is  a  frequent  cause  of  mistaken 
diagnosis.  I  have  seen  this  condition  produce  all  the  rational  symptoms 
anil  physical  signs  of  tuberculosis.  These  cases  usually  present  the 
histdiy  of  an  acute  onset,  with  moderate  constitutional  derangement 
and  hronchitic  disturbance.  The  cough  is  often  paroxysmal,  and  the 
expcctoratidu  purulent,  without  tubercle  bacilli,  or  other  microorgan- 
isms except  the  Pfeiffer  bacillus.  Apropos  of  the  rather  strong  simi- 
larity uf  the  influenza  infection  to  consumption,  I  will  cite  the  report 
of  a  few  cases  which  have  come  under  my  observation. 

Case  1. — A  striking  illustration  of  the  possible  influence  of  this 
infection  was  observed  four  years  ago  in  a  child  of  ton  years  who  was 
placed  in  my  care  about  one  month  after  the  iiiiii:il  dii-et  nl'  her  ilhu'ss. 
In  a<ldition  to  general  symptoms,  includiim  ((niuli.  luss  uf  weight, 
{)hvsical  weakness,  and  aftei'iioon  temjierni  uic  ele\  ;it  iuii.  iliere  exi^ied 

pronounced  coiis.ilidal  i I'  the  lefl    ^ipex.   with   line  moist    lales  in   the 

infected  a,rea..  Dnriimthe  ln||,,u  inuMx  \\cek>  i  he  cdnsdlidatidii  ^i-n.hi- 
ally  extended  downuani  tc  the  Icurth  lil.aii.l  hiwer  ainile  of  the  .scapula, 
witii  moist  rales  thniii-hoiit  this  ic-ion.  'I'here  also  devi^ioped  an  aggra- 
vation of  the  licneral  svin|iloni>.  with  incicasinu  loss  of  weight.  The 
physical  condition  leinaNie.J  stati.maiy  for  the  ensuing  two  or  throe 
months,   when  i^iailnal   iiii|iid\ciMent    i)ei;an   to  l;iki'  |i|ace.      liefore   the 

tion,  with  increased  weight  and  no  reuuuiun?i  exideiice  of  the  slightest 
pulmonary  involvement.  The  child  has  reni.iineil  alisolntely  well  e\(>r 
since.  .Vn  interesting  feature  of  this  case  is  t  he  f.-ict  that  1  he  pi-omcss  of 
the  consolidation  corresponded  to  the  so-called  "line  of  march  "  of  down- 
ward extension  in  tuberculosis  on  which  considerable  stress  has  been  laid 
by  some  observers. 

Case  2. — Another  instance  of  the  possibility  of  error  resulting  from 
the  presence  of  the  influenza  bacillus  was  exhibited  by  a  woman  who  has 
remained  under  my  obs,.|valion  ten  yeais,  displaying,  upon  arrival  in 
Colorado,  signs  of  vei-\-  act  i\c  and  extetisive  tuberculous  infection  of 
each  lung.  There  h,-is  taken  place  an  :ist..nishin,u  ini].rovenieiit ,  includ- 
ing a  gain  of  o\-ei'  loity  p<iuni|s  in  weight  and  a  degree  of  st  length  and 
endurance  quite  exceptional.  l''or  over  four  years  no  bacilli  have 
tieen  ff)und  in  the  s])utum,  in  s])ite  of  frequent  examinations,  and  no 
evidence  of  existing  tubei-culous  activity  in  the  lungs,  though  signs  of 
con.solidation  still  ])orsist.  Two  yoai-s  ago  there  devolopod  a  severe 
influenza  infection,  attended  with  disticssiim  coimh.  copious  ]iurulent 
expectoration,  niodei-.ate  ele\atioii  of  temperature,  and  im))aiiinent  of 
general  strength  and  nutrition.  Kepeated  examuiations  showed  con- 
tinued absence  of  tubercle  bacilli,  yet  the  ])liysii  .il  simis  resulting  from 
extensive  fibroid  change  in  the  lungs  in  connection  with  a  recent 
bronchial  catarrh  suggested  clearly  an  active  ad\ancing  tuberculous 
process. 

Without  the  laboratory  findings  a  precise  conception  of  the  diagnosis 
and  general  outlook  in  ca.ses  of  influenza  infection  following  arrested 
tuberculosis  would  be  utterly  impossible. 

Apart  from  the  influenza  bacillus,  other  microorganisms  have  been 
found  to  exert  an  apparent  influence  in  the  production  of  symptoms 
and  signs  distinctly  indicative  of  tuberculosis.     I  have  observed  several 


296  DIAGNOSIS    AND    PROGNOSIS 

notalilc  insraiices  of  the  relation  of  the  pneumococcus  of  FrietUander 
to  tli(-i'  ili>tiiiliances,  in  the  absence  of  tubercle  bacilli. 

('lis,  :;.  In  1896  a  man  from  Vermont,  recovering  from  tuberculo- 
sis in  Colorado,  was  suddenly  summoned  home  by  the  telegraphic 
announcement  that  his  three-year-old  boy  was  dying  of  acute  pneumonic 
tuberculosis.  He  returned  to  Colorado  immechately,  bearing  in  his 
arms  thr  child,  wiin  had  brcn  alnidst  coniatose  the  entire  distance.  The 
tenipcraturc  liad  rciiiaiiicd  in  ilic  iiciulil  ini'hciod  of  105°  F.  and  the  pulse 
and  ri'.-pi ration,-;  were  Inimd  inaiLcdh'  accelerated.  There  were  mod- 
erate cyano.si.s.  ,<tii|H>r.  and  a  |Milialiv  r,,nM,lidated  right  hmg.  The 
chief  point  of  interest  attaihes  Id  tlie  ilela\id  icscihition,  which  was  not 
completed  for  several  xi'ais.  Tlieic  perM-ied  lor  jidli/  a  year  a  daili/ 
a/tcnioon  rise  oj  ti  inp,  nihir, .  finiliiiinil  rough,  with  signs  of  consolidation 
and  mdist  rales,  irillidiit  hih,i;-li  Imcilli.  The  child  is  now  perfectly 
well,  after  the  lapse  ni  ele\eu  \ears.  physical  examination  of  the  chest 
being  entirely  negative.  It  is  almost  imjiossiMe  tn  cdnceive  of  this 
pneumonia  as  having  been  tuberculous,  not  only  because  of  the  absence 
of  the  bacilli,  but  also  in  view  of  the  comjilete  lei  c>\(rv  in  a  child  so 
young.  Any  attempt  to  explain  the  absence  of  bacilli  by  an  alleged 
miliary  disturbance  with  pulmonary  manifestations  is  almost  entirely 
controverted  by  the  fact  that  the  child  recovered.  Though  undoubt- 
edly an  instance  of  pneuinococcic  inl'ection.  the  peisistence  of  the 
sj'mptoms  and  signs  strc in l;1\-  MiL;'_;e^iiM|  a  tulxTculous  jirncess. 

Casei. — A  woman,  tliirt\  --i\  Maisold.  i-.m^iilnd  me  upon  August  30, 
1907,  four  years  after  the'  devi'lopnieiit  of  puhuonaiy  trouble.  The 
onset  is  of  peculiar  interest.  In  the  mid-t  oT  a  laryimoscopic  application 
at  the  hands  of  a  well-known  laryimoloui>i  a  lari;e  ]j|eilm't  of  cotton  was 
permitted  to  entei-  the  trachea..  This  was  immeiliately  followed  by 
.  the  patient  almost  expiring  from  asphyxia- 
tly  confined  to  the  bed  for  three  months, 
>-t  inressaiit  couuIl  and  ]iaroxysms  of  chok- 
ed to  the  pie-eni  lime.  iIioul  li  cxpectoration 
.en  place  rouMderaMe  lo,-.-,  of  weight  and 
i|M)n  -liulit  exertion.  While  fever  is  not 
perature  is  freqvienth'  elevated  for  weeks  at 
tion  (lis,  loses  evidences  of  moderate  infiltra- 
ni(  li-t  1  ali's  from  apex  to  base,  front  and  back, 
lie  ila\iile  to  the  fourth  rib.  There  is  pro- 
■  liiilit  upper  chest.  Confirmation  of  the 
ob.served  by  reference  to  the  skiagraph 
(Fig.  88).  It  is  scarcely  conceivable  that  the  result-  of  pliysic:d  and 
x-ray  examination  could  indicate  more  clearly  a  genuine  tuberculous 
invasion,  yet  repeated  examinations  of  the  sputum  fail  to  reveal  tubercle 
bacilli.  A  i.eioi  oi  cs-;,.niial  importance  is  the  history  of  an  acute  onset 
of  pulmonai  \  ,-ympioms  I  rom  ob\ious  cause  in  an  individual  previously 
enjoying  good  health. 

Another  condition  which  may  be  the  occasion  of  mistaken  diagnosis 
is  pulmonary  syphilis.  It  cannot  be  doubted  that  this  disease  coex- 
ists with  consumption  oftener  than  is  generally  supposed.  In  some 
instances  the  clinical  evidences  are  confounded  with  those  of  pulmo- 
nary phthisis.  The  subjective  symptoms  of  the  two  are  almost  iden- 
tical, the  cough,  expectoration,  loss  of  weight  and  strength,  and  even 
the  physical  signs  being  very  suggestive  of  ordinary  consumption.     An 


severe  paroxysms  . 

if  eou- 

tion.     She 

was  sii 

bse.p.e 

suffering  g: 

reatly  fi 

■om  all 

ing.     The. 

•ough  h; 

IS  per-i 

is   scanty. 

There 

has    t. 

streiiuth". 

u-itli    ,\\ 

•spne;, 

uniloimly 
■I  time       1 ' 

ll\'~ic-|| 

tion  of  the 

I'ii^ht  lui 

1-.:.  Will 

and  on  tht 

'   lelt    Md 

e    iV.iln 

nounced   r< 

eiractioi 

1     ol'     t 

physical    hndings 

wUl    i) 

iVrfiu-f   ill  t 
iii|i('i'alure. 

lie  clinical    manife.st 
Tlii.s  must  licit   he  i 

ations  is  the  infrequent 
enarded  as  an  invariable 

(■lini;n'lcnst 

ic,  as  it   is  kiKiwii    t 

hat  fever  may   occur  in 

philLS  an.l   1 

.  ai  tul.civl, 
.fan-i(llliV( 

liat  many  cases  of 
111-  iiroloiiged  inti'i\a 
■  liacilli  in  the  expei 
rsti,i:,a.ti(in  iv^anlin- 

c(insuni|iti(in    are   deviiid 

■tciralidii.  Thi-  Mi^uests 
the  hlM,.rv,  whirl,  sli.iuhl 

.dinissi,,.!   (H- 

denial   n!  an   inilial 

lesi.in,    tlie   e\r-lel,re   of 

sh,  ana  liiss 

(if  hair.      Sii|ililenieii 

itai'x'  t(i  this,  theresh, mid 

,  search  l..r 

I'le  (■xternal  evideln 

•es  (if  the  alilecedeiU    dis- 

1,1  l«.  ..nipl.a 

sized  that   the  stiiiit 

est   disaXdW.-il  ,if  :i  .syjihil- 

DIFFERENTIAL    DIAGNOSIS  297 

important  dillY 
elevation  of  I 
distin,!;uishinL 
pulmonary  s\ 
of  teniix'iatni 
by  the  alisem 
the  propriety 
embrace  the 
sore  throat,  r: 
be  instituted 
ease.     It  shoi 

itic  infection,  coupled  with  the  aliseiice  of  clinical  liianhe:  t  at  ions  of  the 
disease,  con.stitutes  no  coiiclusi\'o  evidence  as  to  iis  piv\iou-  non-exist- 
ence. Tlie  grouping  of  the  sulijective  and  object  i\c  syin|itonis  of 
consumption  without  the  bacteriologic  e\'ideiices  is  snihcieiii  to 
awaken  a  suspicion  of  pulmonary  syphilis  and  jnsiiiy  the  iminediate 
employment  of  the  iodids.  That  the  t\\(i  iid'ection-  ((k  \i-t  with  con- 
siderable frequency  no  oliiierver  of  piilnionaiy  tulieniilosis  will  he  dis- 
posed to  deny.  This  subject  will  he  discussed  more  fully  under  (.'om- 
plications. 

The  diagnostic  significance  of  pulmonary  hemorrhage  is  sometimes 
subject  to  erroneous  inter])retation.  In  view  of  the  fact  that  many  cases 
of  pulnional'V  1  ulierculosi^  present  a.  hein(i|-iha'.iic  onset  in  the  ab.sence 
of  previous  sulijecti\-e  symptoius  or  ph>:-ical  si-ns.  il  hillows  that  the 
occurrence  of  hemorrhage,  excn  in  indi\i(!uals  in  ap]ia,reiit  health,  should 
immediateix'  aw  aken  a  si  innu' su.-piciou  of  iucipi,'iit  l  uherculous  iiifeci  ion. 
If  hemorrhage  develops  in.  associaUon  will,  lo:-,-:  of  wemht,  ..lev.aliou  of 
temperature,  and  counh.  e\-en  without  jihysh'al  sii^ns,  a  wananlaMe 
basis  is  furnished  for  ;i  pi'(i\-isional  diauiiosis.  It  i.-  e,--eni  i.mI  ,  liowe\-er, 
in  cases  with  negatiM'  ]il,\>ical  e\idences  of  tuberculosis,  to  eliminate 
all  othei'  condi'ions  possibly  ivsponsible  for  lien,opi y.ds.  t^.everal  times 
I  l,a.\'e  olisei'\-ed  i,em(i,','ha,^es  a n, on ^;-  pal  lent s  p,'esei,i  ing  every  apparent 
sulijective  indicaiioii  of  piili,,onary  I  ill  ei'culosi,-,  in  the  ab.sencc  of 
definite  physical  signs,  tlic  bleediim  beini;-  dependent  upon  other  causes. 
A  citation  of  a  few  cases  may  ihusi  i-aie  the  o],po;  i  unit  \-  foi-  mi- lakes  in 
diagnosis  through  incorrect  inlerpictal  ions  of  the  sii:nif,cance  of  iccur- 
ring  pulnionar\-  helnoiiha'ie. 

The  fir<t  c;ise  ,v|;ite<  to  a  .hk,le(|  :ind  liypertropliied  right  ventricle. 
In  October,  I'.xi.'i.  ,a  woman  of  iwcnty-iwo  years  came  to  Colorado  pre- 
senting the  history  of  a  ]iromcssi\ c  loss  of  wci<;hl  and  sticmith.  with 
cough  and  expectoration,  duiiui;  a  period  of  one  yea,.  Theiv  luid  been 
a  continuous  elevation  of  tenipei-ature.  will,  occasioi,,il  i  lull-  and  nlLzht- 
sweats.  She  had  bled  from  the  lum;s  re]>eated|y.  rpon  the  lia-i~  of 
these  heiuorrhages,  in  connection  with  the  loss  of  wciiiht  and  subjecii\'e 
symptoms,  a  diai;nosis  of  tuberculosis  had  been  made,  and  chanuc  of 
climate  recommended.  Upon  examination,  dulness  was  found  in  the 
left  front  from  the  apex  nearly  to  the  base,  with  comiilete  absence  of 
breath-  and  voice-sounds.  A  supjiosed  ajjcx-beat  was  \isilile  well 
within  the  mammai\-  line,  but  sliuhtly  ele\ated.  In  the  posterior  axilla 
and  in  the  back  ( uackliu-  lales.  ol  a  mcatei'  intensity  than  can  be 
described  or  imai^iued.  wiuc  lieaid.  both  on  inspiration  and  expiration, 
and  recognized  easily  with  the  stethoscope  slightly  removed  from  the 
skin.     No  dulness  was  found  at  the  right  of  the  sternum,  and  it  was 


298  DIAGNOSIS    AND    PROGNOSIS 

almost  impossible  to  outline  the  left  lioundaiy  of  heart  dulness.  The 
cardiac  impulse,  however,  could  be  felt  nearly  to  the  anterior  axillary 
line,  and  murmurs  of  mitral  stenosis  and  regurgitation  were  audible. 
Sputum  examination  was  negative.  A  diagnosis  was  made  of  occlusion 
of  the  left  bronchus  from  a  cUlated  heart.  Hemorrhages  continued 
with  considerable  frequency  during  the  ensuing  six  weeks.  There  were 
also  periodic  attacks  of  alarming  dyspnea  and  cyanosis.  Although  a 
degree  of  dilatation  still  existed  at  the  time  she  was  sent  home,  there 
were  no  symptoms  of  cardiac  embarrassment.  In  front  there  was  con- 
sideral)ly  less  huig  compression  and  all  adventitious  sounds  had  dis- 
appeared from  the  back. 

The  next  lase  illustrates,  in  the  absence  of  mitral  disease,  the  pos- 
sibility of  error  in  ascribing  pulmonary  hemorrhages  to  a  latent  or  con- 
cealed tuberculous  process  even  when  associated  with  loss  of  weight 
and  strength. 

Nearly  twelve  years  ago  a  man  in  middle  life  was  sent  to  Colorado 
for  supposed  tuberculo.sis.  I  found  him  in  bed,  bleetling  from  the 
hmgs  and  coughing  moderately.  The  hemorrhages  hiid  lieen  frequent 
for  several  months,  and  there  had  been  considerable  loss  of  weight 
and  strength.  There  was  marked  pallor,  weak  and  rapid  pulse,  but  no 
fever.  The  examination  of  the  chest  was  entirely  negative.  A  diagnosis 
of  purpura  luemorrhagica  was  sub-c(|uciitl\-  ('stal>lished. 

The  next  case  still  further  illii~i  raic-  tin-  'lifi'n-ulties  encountered  in 
arriving  at  correct  conclusions  (■(nicciiuiii;  the  significance  of  hemoptj-sis: 

A  woman  of  nervous  temperament  was  sent  to  Colorado  in  1899 
on  account  of  very  severe  reciu'ring  pulmonary  hemorrhages.  Her 
husband,  who  was  a  phA-sician,  had  made  a  diagnosis  of  consumption. 
Both  parents  and  three  brothers  and  sisters  had  died  of  tuberculosis, 
she  being  the  only  survivor.  There  was  moderate  dry  cough,  some 
expectoration,  witlr  loss  of  weight  and  a  very  considerable  anemia,  but 
chest  and  sputum  examinations  were  negative.  Shortly  after  arrival 
she  suffered  a  severe  pulmonary  hemorrhage,  followed  by  a  recurrence 
of  like  character  in  exactly  four  weeks.  It  then  developed  upon  inquiry 
that  all  her  previous  hemorrhages  had  occurred  at  a  time  corresponding 
to  the  menstrual  period.  Tlie  diagnosis  of  vicarious  menstruation  was 
promptly  made,  and  the  nature  of  the  condition  fully  explained.  Treat- 
ment referable  to  the  control  of  the  neurotic  conilition  and  the  anemia 
sufficed  to  bring  about  an  ultimate  recovery. 


GENERAL    CONSIDERATIONS  299 

SECTION    II 
Prognosis 


CHAPTER    XLII 
GENERAL  CONSIDERATIONS 

To  the  medical  profession  as  a  whole  the  general  prognosis  of  pulmo- 
nary tuberculosis  has  hitherto  assumed  a  minor  degree  of  importance 
in  comparison  with  other  phases  of  the  t  ulierculdsis  ])i-()ijlem.  Active 
organized  effort  has  Ijccii  i-eiiteicd  hirL;<'l\-  u|miii  ihe  adoption  and  execu- 
tion of  preventive  lueasures,  hut  ihiiuii;  iciciit  \cais  there  also  has  been 
evolved  definite  knowledge  as  to  tlie  curaliilily  n\  the  (li>ease,  b\-  \iitue 
of  patient  and  intelligent  endeavor.  To  the  iniliiKniary  iinalid  pro.ij;- 
nosis  has  ever  been  the  one  feature  of  supreme  iiiieiesl.  luiinechately 
upon  awakening  to  a,  realization  of  ilie  coiiihtioii.  the  paraniotuit  ques- 
tion relates  to  the  chances,  il'  aii\-.  there  aic  lor  rec()\'ery.  The  prognosis 
of  consumption  is  sulije<-t  to  coii-ideraMe  ehisticity  of  interpretation. 
This  is  readily  appreciated  in  noting  the  iniiuiiieral«le  inteiiiieihary 
results  between  complete  recovery  and  early  death.  Ily  ctirf  in  its 
technical  sense  is  meant  the  alisolute  eliniiiuiti<in  of  all  tubeich'  bacilli 
from  the  body.  This  hajip}-  result,  however,  though  possible  of  .attain- 
ment in  exceinional  cases,  is  seldom  acquired.  The  term  "  reco\-eiy" 
is  not  iiiteiKled  to  impl\-  a  complete  restitution  to  the  iioiinal  of 
the  pulnionarv  tissues,  alid  an  eiadicatioii  of  the  bacillarv  inva.lers, 
but  rather  an  emluiin-  n,r,st  <,(  tlie  iiiiectious  proci-s,  'I'lie  ,,i;,rlind 
appliciition  of  pnuiiiosis  relei's  to  wlietliei'  or  not  the  iiilected  individual 
will  be  pernutted  to  secuic  a  i>,  niHin,  „l  i-rst,,rnli„ii  ,,/  j„n,n  r  ,trhritii 
anil  iisrj,il,n.-s.  The  suspeiiM,  ,1,  ,,l  all  ilu  iuediat  el  v  lalal  i~sue.  toll.iwed 
l)y  an  iii.h'lmite  ihtkhI  u(  iiivalidiHu.  shouhl  not  be  .•(,n^ll■l;ed  as  u,,illiy 
oi'  inclusion  under  a,  cjassilicai  ion  of  favorable  results.  The  proper 
interpretation  of  a  so-calle(l  t  a  \-oi  able  prognosis  involves  ,•!  disapjiearance 
of  l)acilliandof  thepliysical  ^i^ns  denoting  active  iindhcmeiit .  an  appar- 
ent return  of  previous  siicnulh  and  vijior.  an  enduiance  which  must  not 
be  subjected  to  umci-onable  tests,  and  a  icstoiat  ioii  o|'  earmii'i  power. 
It  is  evident   tliat    tlie  de-ive  of   anvst    and    the   time   iiece>>ai-y   to|-   its 

The  llexibilitv  .if  its  applicat  ion  is  emphasized  bv  I  he  wide  laiiueof  .•liiiical 
results.  It  is  allotted  to  Muue  to  enjoy  .a  conspiiaious  rehabilitation  of 
health,  with  entile  disappeaiaiice  ol'  subjective  and  objective  signs. 
Others  are  destined  to  secure  a  temporary  respite  from  imminently 
impeii.hiiii  daiiiicr.  with  siibse.nient  partial  arrest  of  the  tuberculous 
proce.ss,  an  indehnite  quiescence  of  the  di.sease  |iermittin,u  a  measure  of 
usefulness,  although  often  in  a  different  sphere  ol  actixity.  The  con- 
sumptive should  be  made  to  understand  that  mice  the  tuberculous 
infection  has  become  active,  no  matter  how  >,iii-i\  nm  the  later  im]iro\'e- 
ment,  the  general  mode  of  existence  is  ik  cess.n  il\  ch.iimi'd  in  maii\-  of  its 
essentials.  In  most  cases  of  arrested  tul>erciilo,~i>  a  minimi  im  of  sac  li  I  ice 
and  suffering  is  secured  only  through  a  contmueil  confoiinity  to  certain 
principles  of  daily  living. 


300  DIAGNOSIS    AND    PROGNOSIS 

The  pi'osnosis  of  consumption  is  not  only  susceptible  of  uncertain 
construction  as  to  its  general  meaning,  but  is  at  best  of  doubtful  defini- 
tion in  IndiriduaJ  cases.  The  formation  of  a  definite  prognosis  is  often 
attended  wit  lit  he  ::ii'ai  est  diiHriilty.  by  \irtiUM  if  the  diverucut  significance 
attaching  to  >\<cr\n\  syiii|ii(.iiis.  (Vitain  cxi-tiuu  nuinilcstations  reflect 
an  important  bcannmijKin ///(///.//((//.  pi-o-iK^is.  altlii.iigh  the  ultimate 
outcome  may  be  modified  greatly  !■>■  the  adxcnt  of  uiiliui'sccu  cdin])!!- 
cations.  Often  the  unexpected  is  ton ud  tn  liappcn.  Many  patients  apjuir- 
ently  doomed  to  death  by  virtue  of  every  arcepted  pid^nu-iic  (•(lusidcr- 
ation  are  seen  to  make  strikingly  pictureMpie  iccoNciies.  wliile  others, 
almost  free  from  the  influence  of  the  di-ea-e.  (|uirkly  sm-cumb  to  an 
intercurrent  pulmonary  hemorrhage,  with  superxcinn-  aspiration  pneu- 
monia. Apropos  of  the  not  infrecpieut  alniipt  dexcldpiiieiit  of  untortu- 
nate  complications.  I  have  in  mind  twoyouim  men  who  ha\-edied  recently 
from  pulmonary  hemorrhage,  alihoimh  ha\iim  exhibited,  during  a 
period  of  two  years,  most  matil\iim  iinpro\eiiieiit  wiih  eoiiiiiU'te  dis- 
appearance of  subjective  synipleiii-  and  inaiked  sub.-ideni-i>  ot  physical 
signs.  These  patients  I  ha<l  re^ai-ded  as  inactically  out  of  (laiiger, 
yet  previous  prognostications  concerning  a  favoralile  issue  in  each 
instance  were  -uddenly  nullified  by  unexpected  pulmonary  hemor- 
rhage. A  siniilai  revohition  in  the  clinical  aspects  is  often  occasioned 
by  other  lause-  ini]  io--il  ile  of  icasonable  anticipation,  as  a  severe  attack 
of  grip,  liionrhoiiiieunionia.  tulii'iiiijoiis  meningitis,  typhoid  fever,  pneu- 
mofhorax.  or  nephriiis.  A  -cries  of  ca.ses  will  be  later  reported  illus- 
tratiim  ilie  oeraMonal  po~-il.ilitv  of  recoverv  even  among  seemingly 
hopele-pulnionarv  mv.alid-. 

It  follows  thai  ilie  pro'.:nosis  in  many  cases,  while  justly  hopeful 
and  reassuiinu',  iiiuM  be  Mimewhat  uuarded  in  I'haraeter.  Special  cau- 
tion sliould  be  exeivi~;',|  noi  lo  pronoiii:i-e  unla\c)i'able  sentence  without 
clue  consideration  ol  all  po^-iMe  phases.  An  aiaairate  prognosis  .seldom 
can  be  made  upon  ihe  ba-is  ol'  the  physical  condition  alone.  The  char- 
acter of  the  subjecti\e  -\inptonis  is  of  the  utmost  importance  in  the 
determination  of  tlie  linai  issue.  It  is  frequently  impossible,  from  pure 
generalizations,  to  arrive  at  correct  conclusions,  as  prognosis  is  largely 
a  question  of  individual  detail.  No  single  factor  shoulcl  be  assumed  to 
be  of  paramount  importance. 

Inasmuch  as  it  is  not  the  disease  alone,  but  rather  the  individual, 
representing  the  necessity  of  clinical  study,  it  follows  that  intelligent 
prognosis  must  lie  reached  throu.sjh  the  combined  influence  of  consider- 
ations pertaining,  first,  to  the  individual,  and.  secondly,  to  the  disease. 


CHAPTER    XLIII 
FACTORS  PERTAINING  TO  THE  INDIVIDUAL 

In  this  general  class  are  included  the  influence  of  a,se,  sex,  race, 
family  history,  individual  resistance,  occupation,  temperament,  dis- 
position, intelligence,  character,  financial  condition,  social  environment, 
personal  equation  in  meilical  supervision,  change  of  surroundings,  and 
climate. 


FACTORS    PERTAINIXG    TO    THE    IXDIVIDUAL 


AGE 

Age  constitutes  an  important  ronsidci-ation  in  the  prognosis  of  con- 
sumption. It  has  loeen  ni\-  cxiiericnrc  that  the  pid^nosis  is  <lecidedly 
less  favorable  in  infancy  and  \(iuth  than  in  :iduil  Inc.  .\i>  (  liihl  under 
eight  years  has  secured  an  ancst  of  pulindiiary  tulx'in  Iom,-  while  under 
my  su])ci\ision.  Not  infrequently,  however,  have  1  lieen  permitted 
to  niite  the  attainment  of  very  satisfactory  results  in  patients  from  eight 
to  fifteen  years  of  age. 

Two  (•(,iisi.i,'ii..us  ciiscs  are  cited  for  tlie  pui-posc  .il'  illust  I'at  ion.  In 
June,  l!)(i:.,  1  dl-clKir-cd  :,.  ciivd  a  Nnv  ,,l  ,.|,.vcii  v..:,i>  whi,  h:id  remained 

under  m\-  (>lis<'i'\  ;il  kmi    hrcrisclx-   l  wd   yr:\v<.      Al    llir   tin l'  arrix'a!   in 

Cohiradn'his  illness  IkmI  I  .eeu  (  ,|  I,,ui  niuntlis'  ,  iui':.  I  i.  ,n  ,  :,.||uwnn:an  ^i.'Ute 
onset  with  rapid  siil  ,-.e(|Uent  .lerjiia  .  whirl,  was  iiKirLed  l.v  1iil:1,  teni|ier- 
atureelevati.in  ami  extivnie  .leMlitv.  .A^  the  det:,il~  .,1  tlu^  .-a-e  will  he 
reported  in  another  i-diiiieci  ion,  ii  i-  sidlicieni  .-ii  tin-  tune  to  e:  II  :inen- 
tion  merely  to  a  tew  es.-enli^il  le:itnres.  'I'here  were  e\t  ivine  ein;iclal  ion. 
pallor,  anil  indnouneeil  dy~piii':i.  the  rhihl,  .-i-  the  n-nlt  of  ph\M.-al 
exhau.stion.  l.eiii'.:  sr:ireel\- alile  lo  st,-ilid  iip.m  lil~  fe.^l.  f:xaliiinat ion  of 
the  chest  dise|..-e,l  tl!ee\iMenceo!e\tenM\C  tnliereiilous  invasion  of  the 
entire  left  liin,-.  'rhroui^honl  I  his  .-ire: 
dences  of  moderate  consolidation,  with 
base.  It  goes  without  saying  that  ; 
almost  unqualifieilly  rendered.  Hy  y\v\ 
rigid  su])ei\ision.   a   snipiising   irnpidxc 

arrest    of    t!:e    tuherrlllous    proress    was    ; 

fibrous  tissue   proliferation.     'I'he   .•hild 

the  past  two  years,  without  xisiMe  retroL^i 

recently  to  examine  the  paiieni.   I   was 

evidences  of  enduring  arre,-t.     Some  idi 

with  resulting  unilateral  deformitv  mav  be  obtained 

Fig.  91. 

In  May,  1906,  a  boy  of  fourteen  was  placed  under  my  care,  six  months 
after  an  abrupt  development  of  pulmonary  tul)errulosis.  The  family 
history  was  excellent.  The  entire  life  of  the  chihl  had  heen  ~pent  in 
New  Mexico  until  the  earlv  fall  of  1905.  when  the  famih-  removed  to 
Los  Angeles.  A  severe  cohl  di'velopcd  shortly  afterward,  with  per.sisting 
cough,  expectoration,  temperature  elex'ation.  and  loss  of  W(auht.  Upon 
arrival  in  Colorado  tlie  |iatient  was  anemic  and  much  (leMlitated.  On 
examination  of  the  chest,  moist  rales  were  recoi:nized  in  the  left  front, 
from  the  apex  to  the  third  rib,  and  upon  the  ri-ht  side,  from  the  apex 
to  the  .'iecond  interspace.  The  left  back  was  clear,  but  u|ion  the  right 
side  moisture  was  detected  to  the  lower  third  of  the  interscapular  space. 
Tubercle  li.icilli  were  exceedingly  iiunierou.s.  In  view  of  the  marked 
coiisiituiional  change  and  extern  of  i  uberculous  involvement  the  prog- 
nosis was  at  best  extremely  guarded,  I'liiler  strict  disciplinary  con- 
trol a  gain  of  lifty-li\e  pounds  w.is  .'ichiexcd  in  six  months.  There  is 
now  no  temperature  elexatioii.  cou,uh.  <ir  expeit(nation.  Examination 
of  the  chest  discloses  entire  absence  of  moisture  in  both  lungs.  The 
excellence  of  nutrition  is  displayed  in  the  accompanying  photograph 
(Fig.  92). 

Clinical  observations  of  this  character  have  forced  the  conviction 
that  the  prognosis  of  pulmonary  tuberculosis  is  decidedly  better  between 


detect 

e<l    ],hvsic;,l     evi- 

l.ilM     r;i 

les    from    apex    to 

lav,,r;d, 

le    progiM.-^i-    was 

the   I'lil 

iieil,     Tlie   entire 

I'd    li\- 

an   extraordinary 

niame.l 

at    home   during 

,       [-\n, 

(lie   uiuni-takalile 

U<    tlie" 

btameti 

1  t)y  reference  to 

302 


DIAGNOSIS    AND    PROGNOSIS 


the  ages  of  eight  and  fifteen  than  prior  to  eight,  or  between  fifteen  and 
twenty.  In  early  life  the  process  is  invariably  more  active  than  in  sub- 
sequent years,  the  absorptive  powers  being  much  greater  antl  toxemia, 
as  a  rule,  more  profound.  It  is  also  likely  that  the  capacity  for  absorp- 
tion of  toxic  products  is  greater  from  eight  to  fifteen  than  in  the  imme- 
diately ensuing  years,  but  its  influence  is  more  tlian  offset  by  the  far 
greater  docility  of  patients  at  such  time  of  life  than  in  the  years  approach- 
ing manhood.  Children  around  twelve  are  less  inclined  to  disobedience, 
and  much  more  amenable  to  discipline  than  in  the  neighborhood  of 
fifteen  to  twenty.  At  the  latter  period  they  are  more  apt  to  be  willful 
and  difficult  of  restraint,  even  if  without  tendency  to  viciousness.  This 
is  e.specially  noticeable  among  young  people  who  have  been  subjected  to 
the  pernicious  influence  of  indiscriminate  petting  and  parental  indul- 


gence. The  management  of  such  patients  is  often  fraught  with  exceed- 
ing difficulty,  .\lthough  the  natural  disposition  may  be  gentle  and 
kiiuUy.  the  temperament  not  essentially  irritable,  and  the  manner  not 
domineering,  the  formation  of  character  is  necessarily  incomplete,  there 
often  l)eing  exhibited  an  unfortunate  lack  of  .self-contrcl  or  submission 
to  the  advice  of  others.  Patients  at  this  age  have  not  reached  years 
of  discretion,  and  have  not  been  permitted  to  acquire  that  maturity  of 
judi;ineut  which  is  necessary  to  successful  results.  It  has  been  my 
obsorxation  that  the  prognosis  has  improved  with  every  semidecade 
from  twenty  to  fifty,  and  diminished  from  that  time  onward.  This  has 
been  more  particularly  tnie  among  males  than  females.  In  the  latter, 
on  account  of  the  menopause,  with  its  attending  nervous  disturbances, 
I  have  found  the  best  results  to  obtain  in  the  fifteen-year  period  from 
thirty  to  forty-five. 


FACTORS    PERTAINING    TO    THE    INDIVIDUAL 


The  influence  of  sex  has  been  found  to  be  of  considerable  prognostic 
importance,  decidedly  better  results  being  observed  among  females 
than  males.  This  is  contrary  to  the  prevalent  impression  regarding 
the  bearing  of  sex  upon  prognosis,  but  the  evidence,  from  my  own 
experience,  has  been  so  overwhelming  as  to  permit  no  other  conclusion. 
In  this  connection  it  is  interesting  to  note  that  the  disease  is  generally 
considered  to  attain  a  greater  prevalence  among  females,  on  account 
of  their  relatively  diminished  powers  of  resistance  and  their  lessened 
opportunities  for  outdoor  air,  sunshine,  and  exercise.  It  has  been 
assumed  that  these  causes,  sufficient  to  in  rite  bacillary  infection,  may 
exert  an  unfavorable  influence  upon  the  suhx((iiu>it  course.  It  is  note- 
worthy that,  as  a  general  rule,  ojijiorluiiilns  for  prnnioting  recovery 
through  change  of  climate  and  pn\ii(iiiiiiciit  ;iic  not  uttered  to  the  female 
equally  with  the  male.  If  eneruct  ir  iik^imiivs  in  the  way  of  climatic  change 
and  rational  management  aic  insiiiuicd  at  all  for  the  female,  they  are 
often  deferred  to  later  St  a  i;rs  <il'  tlir  ili-case.  In  comparison  with  the 
promptness  and  celerity  with  which  niah'  niciiibcrs  (if  tlie  family  hasten 
to  avail  themselves  of  all  pdssihh'  incaiis  il'  aricsl,  the  tactics  disjilaved 
for  the  relief  of  the  feniah's  appear  cs]iccially  .hhiloiy.  It  is  somcwluit 
surprisiiii:  that  tin-  man  of  affairs,  thr  tiailcsinaii.  the  ]ii(itcs,-i(iiial  man, 
and  even  tlic  wai^c-carner  seems  bettci- a.hh'  iosc\cr  liimsclf  iioin  his  busi- 
ness responsiliihiics  than  the  houscwilc  lioui  licr  iloiiicstic  cares.  Fi-om 
my  observation  it  apjicai-s  th;it  no  saciidcc  is  too-uivat  to  (Icier  the 
males,  in  general,  from  seeking C'lrh'  all  p(l^^ill|e  aids  toward  recox'ciy. 
The  above  coiisideratioiis  would  suu-.-est  aliiiosi  uiiax-oidably  a  pro- 
nounced uufaN-oi-dile  pi'o-iioH  allachiim  to  I  id  leiculoMs  in  the  leliiaie, 
yet  despite  ad\cr-e  coiidniiiii-  .-nid  c(iiitrar\-  to  the  (.|iiiii()iis  of  ot  hers, 
it  is  shown  tliat  the  iiltiii. .■,].■  oiit|o(,k  is  .■icluallv  belter  for  fenialos  than 
for  males.  This  conclusion  has  been  reached  not  from  statistical  argu- 
ments, which  are  often  lall.-icious.  hut  |iui-ely  from  the  lofiie  of  e\-ery-(lay 
experience.  Upon  reflection  it  is  eas\  to  understand  why  the  tnenibers 
of  the  female  sex  should  exhibit  the  better  |iro,iiiiosis.  Success  (_ir  failure 
in  the  struggle  to  overcome  tiie  iinasion  by  the  tubercle  bacillus 
depends  largely  upon  the  ability  of  the  indixidual  to  conform  to  a  strict 
regime,  which  demands  for  its  most  satisfactory  accomplishment  certain 
physical,  mental,  and  nel•^•ous  re(|uireiiients.  Assuredly  these  are 
possessed  to  a  greater  extent  by  the  feniale.  .Mthousih  admittedly 
more  susceiitible  to  ner\-otis  influences,  nevertheless,  in  the  event  of  a 
tuberculous  infect  ion.  she  is  iiell(>r  equipped  by  virtue  of  inherent  and 
acquired  tendencies  to  adapt  herself  to  unusual  conditions.  She 
exhibits,  to  a  marked  extent.  ;i  diminished  restlessness  under  imposed 
restraint,  suffers  a  lesser  strain  incident  lo  the  cures  and  responsibilities 
of  life,  and  bears  a  lighter  biiiden  of  lin.mcial  obligations.  In  addition, 
she  manifests  far  less  tendency  to  acts  of  iin|iru(lciice  and  dissipation. 
She  not  only  yields  a  more  read\-  accept.-ince  ol  the  luinciples  of  eaily 
supervisory  control,  but  her  subse(|uent  obedience  and  com])|iance  with 
detailed  instructions  are  more  complete  and  implicit.  Only  in  exceptional 
instances  is  separation  from  family,  either  in  favorable  climates  or  in 
sanatoria,  harder  for  the  female  than  for  the  male.  In  open  health 
resorts  the  hu.sband,  if  stricken  with  tuberculoisis,  is  often  accompanied 
by  his  wife,  while  the  woman,  if  similarly  afflicted,  is  usually  alone.     It 


304  DIAGNOSIS    AND    PROGNOSIS 

will  lie  cxiilainoil  later  that  in  the  majority  of  instances  the  prospects 
of  a  s\i((i'— ml  i-<ue  are  materially  improved  by  the  absence  of  the 
hu.sl)aU(l  HI  (Jihci  members  of  the  family.  It  cannot  be  denied  that  the 
percentage  of  improvement  among  females  is  remarkably  greater  in 
those  who  are  either  unmarried  or  without  laiiiily  iucunibiauce. 

An  important  factor  in  explanation  of  the  I>cUit  inoguii-is  ni  females 
relates  to  the  ver>-  fart  of  their  precious  imloor  environment  and  the 
more  complete  siilis((|ii('iit  transformation  of  the  mode  of  life.  Another 
element,  ajtpliiaMi'  particularly  to  tho.se  who  seek  climatic  change, 
con.sists  of  the  relatix'ely  su]HMi(ir  fiiianeial  ciicunisiaMces  of  the  female 
invalid.  Unfortiuiateiy.  ycMiim  men  with  exieu-nc  tuiierculous  involve- 
ment and  sa(ll>-  iiia(lci|uate  resources  are  niieii  sent  to  health  resorts 
with  instructions  to  secure  immechate  employment.  Many,  financially 
im])overished,  are  compelled  to  work  for  a  mere  pittance  in  order  to 
supply  the  imperative  necessities  of  life.  Further  commentary  is  to 
the  effect  that  while  females  are  not  iiri\ileL;ed  to  take  advantage  of 
climatic  change  as  frequentl\-  a~  male-,  as  a  lule.  they  are  not  hurried 
to  health  resorts  without  proper  pri)\  i-mu  heuig  made  for  their  support. 

RACE 

Race  has  ever  been  found  to  exercise  a  con.siderable  influence  upon 
the  determination  of  final  results,  as  has  been  made  clear  in  an  earlier 
chapter.  (See  p.  59.)  Its  prognostic  import  may  be  regarded  as  a 
clinical  truth  incapable  of  controversial  ar^uineiii.  although  the  actual 
scope  of  its  effect  and  the  precise  manner  in  which  it  is  exerted  may  be 
subject  to  considerable  variation.  Its  jini-nn-i  k-  liearing  is  due  not 
infrequently  to  national  differences  of  siisre|itil>ility  to  the  disease. 
The  utter  lack  of  resistance  against  the  rava'.;e- .  .1  1  ul  lerculosis  is  exempli- 
fied particularly  by  the  prevalence  and  m(Hta.lii\-  <il  the  disease  among 
the  Ameiicaii  Tinlians.  Its  rapid  dissemination  among  these  people 
cannot  be  explained  by  the  lack  of  outdoor  air,  sunshine,  and  exercise, 
or  by  the  ina--inL;  of  large  numbers  of  people  in  relatively  confined 
sections.  While  sources  of  bacillary  infection  must  exist  to  a  degree  in 
order  to  render  possible  the  transmission  of  the  disease,  the  essential 
consideration  relates  to  the  inherent  vulnerability  of  the  tissues. 

Likewise  among  the  negroes  the  morbidity  of  consumption  is  explained 
in  part  by  an  undue  racial  predisposition.  That  this  does  not  constitute 
the  sole  consideration  is  shown  by  the  great  infrequency  of  the  ili.sease 
prior  to  enfranchisement  of  the  race.  The  stibsequent  obligatory 
assumption  of  responsibilities  to  which  they  were  ill  adapted,  together 
with  squalid,  unhygienic  .surroundings,  have  effected  a  diminution  of 
vital  re<i<taiiie  and  afforded  means  of  acquired  infection.  Complete 
and  eniluriiiL;  aiicst  of  pulmonary  tul>erculosis  is  extremely  rare  among 
the  colored  rail',  although  I  have  seen  a  few  notable  instances  of  such  an 
occurrence  in  Colorado.  The  course  of  the  disease  is  usually  rapid, 
attended  with  progressive  excavation,  and  marked  by  a  high  degree  of 
toxemia. 

A  striking  illustration  of  the  occasional  complete  arrest  of  the  tuber- 
culous process  in  the  negro  is  found  in  the  following  case:  The 
patient,  aged  forty-five,  developed  well-defined  evidences  of  ptilmonary 
tuberculosis  two  years  ago.  The  phy.sical  examination  disclosed  a 
massive  consolidation  of  the  left  lung,  with  characteristic  constitutional 


FACTORS    PERTAINING    TO   THE    INDIVIDUAL 


305 


disturbances,  the  loss  of  weight  and  general  prostration  being  pro- 
nounced. There  has  taken  place  an  entire  arrest  of  the  tuberculous 
process,  with  complete  absence  of  subjective  symptoms.  The  extent 
of  pathologic  change  is  illustrated  in  the  skiagraph  recently  taken 
(Fig.  57),  and  the  present  excellent  nutrition  in  Fig.  93. 

It  should  be  added,  however,  that  this  rather  unusual  result  is  largely 
explained  by  the  fact  that  exceptional  opportunities  were  afforded  for 
securing  an  arrest. 

The  prevalence  of  the  disease  and  its  high  mortality  rate  among  the 
Irish  people  can  hardly  be  explained  by  their  social  conditions  or  methods 
of  living.  A  decided  lack  of  resistance  is  exhibited  by  the  wealthy 
and  highly  educatetl,  as  well  as  by  the  poor  and  ignorant.  It  must  be 
assumed  that  Celtic  temperamental  characteristics  have  an  intrinsic 
bearing  upon  the  prognosis.  Though  brave  to  a  remarkable  degree  in 
the  face  of  imminent  danger,  the  Irish  courage  in  the  absence  of  a  critical 
emergency  is  not  attended  with  that  unswerving  tenacity  of  purpose  so 


Fig.  g.S.— Compl 


of  advanced  tuberculous  infection  in  negro. 


necessary  for  the  maintenance  of  a  protracted  regime.  The  prognosis 
among  the  Irish  is  less  favorable  than  in  any  other  Caucasian  race. 
Their  neighbors,  the  Scotch,  although  endowed  with  less  mercurial 
tendencies,  are  often  more  difficult  to  manage  on  account  of  their  prover- 
bial stubborn  characteristics,  a  continuous  suitable  regime  being  fre- 
quently out  of  the  question. 

The  Swedes,  from  my  personal  observations,  appear  to  be  more  sus- 
ceptible to  consumption  than  the  Norwegians,  Danes,  or  Dutch.  In 
spite  of  their  historic  endurance  and  hardiness,  they  have  exhibited  an 
unexpected  lack  of  resistance  after  the  infection  is  established. 

The  English  and  Germans  particularly  excel  in  their  unwavering 
adherence  to  a  fixed  systematic  regime.  I  have  found  the  prognosis 
among  these  people  markedly  favored  by  their  dogged  perseverance  in 
endeavoring  to  secure  arrest,  unmindful  of  external  distractions  and 
allurements. 


306  DIAGNOSIS    AND    PROGNOSIS 

The  Americans  offer  a  less  favorable  prognosis  than  their  more  stoical 
kindred  of  English  descent  or  their  phlegmatic  German  cousins.  The 
spirit  of  unrest  and  endeavor  incident  to  the  strenuousness  of  American 
life  characterizes  to  a  certain  extent  the  pulmonary  invalid  of  our  own 
country.  All  too  frequently  it  is  asserted  that  recovery  must  take 
place  within  a  certain  stipulated  time  limit,  which  represents  the 
maximum  period  allotted  for  the  consummation  of  the  desired  result. 
The  American  charges  into  the  proposed  struggle  for  arrest  with  an 
impetuosity  and  enthusiasm  corresponcUng  to  the  energy  displayed  in 
commercial  life  or  professional  pursuits.  Upon  attaining  a  tangible 
improvement,  he  frequently  cannot  refrain  from  resuming  his  former 
duties,  despite  an  incomplete  arrest  of  the  tuberculous  process. 

Of  all  people,  the  Hebrews  present  the  most  unique  and  picturesque 
exhibition  of  racial  influence  upon  the  prognosis  of  consumption.  The 
historic  condemnation  of  the  Jews  to  the  ravages  of  disease  seems 
literally  to  have  been  fulfilled  in  the  prevalence  of  tuberculosis  among 
these  sorely  afflicted  people.  In  direct  accordance,  however,  with 
their  wonderful  survival  of  persecution  is  observed,  in  many  instances, 
a  remarkable  immunity  to  the  toxins  of  pulmonary  phthisis.  Though 
quite  susceptible  to  infection  and  unable  frequentlj'  to  overcome  the 
tuberculous  process,  the}-,  nevertheless,  exhibit  powers  of  resistance 
which  are  indeed  marvelous,  despite  the  existence  of  extensive  areas  of 
destructive  change.  Early  in  my  experience  with  pulmonary  invalids 
there  was  noted  in  Hebrew  patients  a  disproportion  between  the  physical 
signs  and  the  general  condition.  While,  as  a  rule,  the  course  of  the 
disease  is  prolonged  indefinitely,  the  process  of  arrest  is  slow  and  dis- 
appointing. The  Jew  is  usually  obedient  and  conscientious  to  the  last 
degree  in  following  instructions. 

FAMILY  HISTORY  AND  PREVIOUS  HISTORY 

The  etiologic  relation  of  an  inherited  predispo.sition  has  been  dis- 
cussed in  a  previous  chapter.  After  the  disease  is  acquired,  the 
family  history  must  be  accepted  as  having  some  bearing  upon  the 
ultimate  outcome,  although  its  prognostic  import  is  not  a  factor  of 
especial  importance.  The  absence  of  a  tuberculous  family  history  has 
but  slight,  if  any,  favorable  significance,  but  a  strong  hereditarj'  taint 
renders  the  outlook  for  eventual  arrest  somewhat  more  gloomy  in  the 
majority  of  cases.  A  negative  history  of  tuberculosis  among  immediate 
ancestors,  if  accompanied  by  a  record  of  several  deaths  among  the 
brothers  and  sisters,  must  be  construed  to  indicate  an  impaired  resistance 
characterizing  the  present  generation.  Deaths  among  brothers  and 
sisters  are  frequently  observed  to  take  place  at  about  the  same  age, 
suggesting  that  the  powers  of  resistance,  sufficient  to  withstand  infection 
up  to  a  certain  point,  are  finally  exhausted.  Such  a  family  record 
is  undoubtedly  a  factor  worthy  of  some  consideration  in  a  determinatiop 
of  the  individual  prognosis. 

The  prognosis  is  influenced  to  a  marked  degree  by  the  apparent 
resistance  of  the  indrndiial .  as  exhibited  in  a  review  of  the  previous 
career.  This  should  embrace  the  history  of  infancy  and  early  life,  the 
record  of  previous  di.seases,  their  duration,  severity,  sequel*,  and  an 
inquiry  of  past  and  present  habits.  Children  whose  parents  (either  one 
or  both)  at  the  time  of  conception  were  exhausted  by  disease  or  dissipa- 


FACTORS    PERTAINING   TO   THE    INDIVIDUAL  307 

tion,  are  likely  to  be  puny  and  delicate  in  infancy  and  to  present  the 
history  of  many  severe  illnesses  during  later  childhood,  with  distinct 
manifestations  of  impaired  strength  and  vitality  in  adult  life.  This 
element  of  diminished  resistance  to  disease  is  shown  in  prolonged  and 
tedious  convalescence  from  typhoid  fever  or  other  constitutional  affec- 
tions. If  to  such  a  history  as  this  are  added  the  unfortunate  effects  of 
dissipation  or  excesses  of  any  nature,  there  results  an  inevitable  shadow 
upon  the  final  prognosis. 

OCCUPATION 

Considerable  importance  has  always  been  attached  to  the  influence 
of  certain  occupations  upon  prognosis.  The  inhalation  of  palpable  dust 
by  stone-cutters,  glass-workers,  potters,  millers,  grinders,  and  either 
coal  or  metalliferous  miners  has  been  regarded  as  particularly  unfavor- 
able. Conclusions  entertained  with  reference  to  the  unfortunate  out- 
look for  such  persons  are  unquestionably  correct,  although  the  tuber- 
culous element  in  these  cases  is  entirely  secondary  to  the  antecedent 
pathologic  change.  While  consumption  is  not  the  essential  cause  of 
death,  the  fact  remains  that  the  ingrafting  of  a  terminal  bacillary  infec- 
tion upon  a  combination  of  morbid  conditions,  as  chronic  bronchitis, 
emphysema,  pneumonokoniosis,  and  circulatory  disturbance,  carries  with 
it  a  profound  impression  as  to  a  fatal  issue. 

Generally  speaking,  the  prognosis  is  bad  among  people  whose 
occupation  involves  confinement  during  many  hours  of  the  day,  in 
small,  ill-ventilated,  and  overheated  rooms,  as  in  factories  and  work- 
shops. It  is  universally  conceded  that  people  engaged  in  indoor  pur- 
suits with  marked  sedentary  habits  are  more  likely  to  become  subjects 
of  tuberculous  infection  than  their  more  fortunate  fellows  who  enjoy 
an  outdoor  existence.  It  does  not  follow,  however,  that  the  former 
class  possesses  inferior  opportunities  for  subsequent  recovery.  The  pri- 
mary causal  factor  among  such  individuals  relates  to  a  diminished  resis- 
tance resulting  from  impaired  general  health.  This  may  react  to  their 
ultimate  di.sadvantage  chiefly  from  a  continuance  of  the  same  unfavor- 
able environment.  It  has  been  my  observation  that  invalids  previously 
subject  to  more  or  less  confinement  are  afforded  a  much  better  outlook 
after  they  conform  to  a  system  of  rational  management  than  those 
who  have  pursued  an  active  outdoor  occupation.  An  explanation  of  the 
more  favorable  prognosis  in  the  former  group  is  found  in  the  more  radical 
change  in  mode  of  life  and  consequently  a  greater  impression  upon  the 
general  health. 

Farmers  and  athletes  who  not  only  are  accustomed  to  living  out-of- 
doors,  but  also  are  trained  to  superior  muscular  development,  are  less 
likely  to  get  well  after  consumption  has  been  contracted  than  those  occu- 
pying clerical  positions.  Thus  the  bookkeeper,  who  sits  for  hours  at  his 
desk  in  a  cramped  anterior  po.sture,  though  much  more  likely  to  develop 
tuberculosis  than  the  team-driver,  offers  a  much  better  prognosis.  The 
change  to  an  outdoor  life  is  usually  followed  by  immediate  general 
improvement,  which  is  denied  to  those  already  habituated  to  an  open- 
air  existence.  Among  no  class  of  people  is  the  disease  attended  with 
less  favorable  results  than  in  those  accustomed  to  feats  of  physical 
strength  involving  prolonged  effort  and  unusual  endurance.  In  the 
same  way  it  has  been  my  observation  that  the  more  favorable  the 


308  DIAGNOSIS    AND    PROGXOSIS 

climate  in  which  the  infection  occurs,  the  less  hopeful  the  prognosis. 
In  Colorado,  while  indigenous  consumption  is  relatively  infrequent, 
when  once  acquired,  the  subsequent  course  is  usually  rapid. 

TEMPERAMENT,  DISPOSITION,  INTELLIGENCE,  AND  CHARACTER 

There  are  but  few  favorable  factors  influencing  prognosis  of  greater 
import  than  a  phlegmatic  attitude,  gentleness  of  disposition,  alertness 
of  intellect,  and  strength  of  will.  Individuals  endowed  with  a  philo- 
sophic temperament  are  less  subject  to  nervous  irritation,  resulting  from 
the  annoyances  and  worriments  incident  to  their  environment  and  the 
indefinite  period  of  invalidism.  The  benefit  accruing  from  such  a  tem- 
perament is  greatly  accentuated  by  a  cheerful  disposition,  keen  intelli- 
gence, and  strength  of  character.  The  stoical  attitude,  if  not  thus  rein- 
forced, may  be  less  advantageous  even  than  a  distinctly  nervous  tem- 
perament, supplemented  by  mildness  of  cUsposition,  firmness  of  will, 
and  refinement  of  manner.  I  have  found  improvement  in  patients 
exhibiting  decided  nervous  tendencies  without  pronounced  neiu-oses, 
quite  as  frequently  as  among  those  devoid  of  all  e.xcitable  proclivities. 
This  is  due  to  the  fact  that  such  persons  are  more  keenly  alive  to  the 
importance  of  their  condition,  more  amenable  to  advice,  and  more 
conscientious  in  observing  specific  instructions.  While  in  general  the 
phlegmatic  temperament  is  assuredly  more  conducive  to  good  results 
than  the  irritable  or  unstable,  an  attitude  moderately  nervous  often 
affords  more  active  cooperation  and  obedience  on  the  part  of  the 
patient.  Rather  high  degrees  of  irritability  present  serious  obstacles 
to  a  successful  issue,  but  simple  restlessness  and  excitation  of  manner, 
under  rigid  and  tactful  management,  may  yield  fairly  satisfactory  re- 
sults. As  the  neurotic  disturbance  increases  the  balance  at  once  is 
thrown  to  tlie  disadvantage  of  the  individual.  While  the  exhibition  of 
nervous  tendencies  always  imposes  more  exacting  demands  upon  the 
energy,  patience,  and  skill  of  the  medical  adviser,  a  resourceful  and  tactful 
response  is  frequently  sufficient  to  minimize  their  unfavorable  influence. 

Innate  cheerfulness  of  disposition  modifies  prognosis  to  an  enormous 
extent,  as  the  time  element  in  the  arrest  of  the  disease  makes  unceasing 
call  upon  the  patience  and  hopefidness  of  the  invalid.  The  optimism 
of  the  cheerful  and  sanguine,  supported  by  an  active  cooperation,  is  far 
more  desirable  than- the  pessimism  of  the  depres.sed  and  melancholic, 
even  if  accompanied  by  passive  obedience  to  instructions.  A  happy, 
contented  disposition  enables  the  invalid  to  make  the  most  of  all  suc- 
cesses and  to  minimize  the  import  of  temporary  discouragements. 
Patients  displaying  a  despondent  or  surly  nature,  on  the  other  hand, 
are  unwilling  to  accept  the  true  significance  of  any  favorable  aspect,  and 
are  apt  at  all  times  to  misconstrue  motives,  exaggerate  trifles,  and  take 
offense  at  imaginaiy  slights. 

Discriminating  intelligence  is  of  the  utmost  value,  as  it  insures  in 
the  mind  of  the  individual  a  precise  conception  of  the  nature  of  the 
disease  and  the  manner  in  which  an  arrest  may  be  secured.  It  often 
affords  a  comprehensive  understanding  of  the  rationale  of  therapeutic 
methods,  and  tluis  permits  a  far  more  ready  acceptance  of  the  enforced 
regime.  To  .such  patients  there  is  usually  but  little  occasion  for  argu- 
ment, as  a  simple  statement  of  directions  is  sufficient  to  entail  implicit 
obedience  and  to  establish  relations  of  mutual  sympathetic  cooperation. 


FACTORS    PERTAINING    TO   THE    INDIVIDUAL  309 

The  character  of  the  patient  is  of  vast  importance  in  the  continuous 
maintenance  of  an  enforced  regime.  An  unyielding  determination  to 
succeed  is  of  no  less  value  in  the  effort  to  recover  from  consumption 
than  in  other  departments  of  human  endeavor.  Strength  of  will  enables 
the  invalid  to  rise  above  temporary  obstacles  and  discouragements  to 
which  the  weak  and  vacillating  often  succumb.  Patients  exhibiting 
indomitable  perseverance  and  tenacity  of  purpose  may  be  depended 
upon  to  pursue  steadfastly  the  course  which  has  been  outlined,  regard- 
less of  distracting  influences. 

FINANCIAL  CONDITION 

The  financial  status  must  be  regarded  as  a  factor  of  considerable 
importance  in  the  ultimate  prognosis.  There  is  a  measure  of  truth  in 
the  saying  "Only  the  rich  can  afford  to  have  consumption."  Such 
aphorisms,  however  trite,  fail  to  convey  accurately  and  completely 
the  logic  of  actual  facts.  Although  embarrassed  resources  certainly 
represent  in  many  cases  a  serious  obstacle  to  the  attainment  of  best 
results,  a  large  number  of  pulmonary  invalids,  despite  this  hancUcap, 
are  enabled  to  achieve  final  success.  It  is  not  so  much  the  size  of  one's 
bank  account  which  permits  a  comparatively  easy  path  toward  arrest, 
but  rather  the  judicious  adaptation  of  the  method  and  environment 
to  the  available  funds.  It  has  been  my  experience  that  impecunious 
circumstances,  unless  extended  to  the  point  of  abject  penury,  furnish 
no  insurmountable  difficulties  in  the  way  of  recovery.  There  is  likely 
to  exist  among  the  poor  a  keener  appreciation  of  the  exigency  confront- 
ing them,  and  hence  a  lesser  likelihood  of  retrogression  through  dis- 
sipation, frivolous  excesses,  or  other  acts  of  indiscretion.  The  desire 
to  take  advantage  of  every  reasonable  facility  at  their  command  is 
especially  overpowering  to  patients  with  small  means  or  those  dependent 
upon  the  assistance  of  others.  By  virtue  of  their  financial  limitations 
there  is  usually  observed  a  conscientious  adherence  to  the  principles  of 
systematic  living.  The  financial  condition  is,  at  the  very  most,  but  a 
single  factor  among  many,  each  of  which  has  its  due  weiglit  in  a  deter- 
mination of  the  final  issue.  Even  a  greatly  restricted  incnme,  if  asso- 
ciated with  other  conditions  of  favorable  moment,  is  more  to  be  desired 
than  affluence  if  unattended  by  siinil.Mi-  ]iro|iitious  factors.  The  pro- 
longed period  of  invalidism,  the  deinninl  Im  su]ieralimentation,  and  the 
requirement  of  a  proper  social  ami  hy^iciuc  environment  illu.strate 
the  value  of  an  ample  fortune,  but  not  its  invariable  necessity.  In 
view  of  the  sanatorium  provision  in  many  parts  of  the  country,  a  meager 
monthly  allowance  is  often  sufficient  to  supply  actual  needs.  For 
people  with  inadequate  resources,  however,  a  practical  difficulty  is 
experienced  at  the  time  of  departure  from  sanatoria.  The  end  of  their 
stipulated  period  of  regime  is  followed  in  many  instances  by  a  return 
to  work  and  to  an  eminently  unsuitable  environment.  A  rational 
solution  of  the  problem  for  such  invalids  consists  of  the  excellent  oppor- 
tunities at  their  disposal  in  favorable  climates.  A  class  of  patients  with 
limited  means,  though  not  absolutely  impecunious,  are  offered  assuring 
possibilities  of  improvement  from  climatic  change,  provided  accurate 
information  is  obtained  in  advance  concerning  appropriate  accommoda- 
tions at  a  minimum  expense.  Patients  dependent  largely  upon  their 
own  efforts  for  support,  but  exhibiting  only  incipient  infection,  are  often 


310  DIAGNOSIS    AND    PROGNOSIS 

permitted  to  secure  arrest  through  outdoor  employment  in  favorable 
regions.  Many  who  are  less  fortunate  than  their  fellows  in  their  finan- 
cial equipment,  possess  other  compensatory  factors  of  favorable  prognos- 
tic import,  and  with  slight  assistance  in  the  beginning,  are  restored  to 
their  former  usefulness  and  activity.  This  course  of  remark  is  pre- 
sented to  emphasize  the  fact  that  a  moderately  restricted  income  is  not 
in  itself  an  insurmountable  obstacle  to  success. 

SOCIAL  ENVIRONMENT 

Few  factors  pertaining  to  the  future  welfare  of  the  patient  are  of 
more  importance  than  a  hopeful  and  cheerful  social  atmosphere.  In 
some  cases  the  presence  of  the  husband  or  wife  may  be  of  inestimable 
benefit  in  promoting  the  comfort  and  contentment  of  the  invalid,  and 
in  guarding  against  indiscretions.  In  other  cases,  no  matter  how  well 
conceived  the  intention  or  devoted  the  service,  incalculable  injury  is 
inflicted  through  absence  of  tact,  perversions  of  judgment,  and  obliqui- 
ties of  disposition.  Little  children  may  be  regarded  in  all  instances 
as  decided  incumbrances  to  the  progress  of  the  patient,  although  mothers 
are  prone  to  insist  upon  their  decided  influence  for  good,  and  protest 
strenuously  against  even  a  temporary  separation.  There  is  imposed  a 
demand  for  careful  individualization  under  such  circumstances,  pre- 
cipitate action  not  always  improving  the  immediate  prospects  of  the 
invalid.  In  general,  children,  regardless  of  their  intelligence  or  gentle- 
ness of  disposition,  are  of  necessity  a  source  of  added  care  and  anxious 
responsibility  and  cannot  fail  to  disturb  to  a  marked  extent  the  quiet 
regime  of  invalidism.  Segregation  of  the  patient  insures,  in  the  majority 
of  cases,  more  satisfactory  results  than  are  otherwise  attained.  The 
ready  adaptation  of  the  consumptive  to  a  proper  social  environment 
affords  in  part  a  favorable  estimate  as  to  the  possibility  of  final  arrest. 
It  should  be  remembered  that  it  is  not  the  patient  alone  whose  temper- 
amental peculiaiities  demand  thoughtful  consideration,  but,  unfortu- 
nately, the  accompanying  relatives  as  well.  Many  invalids  are  com- 
pelled to  pay  the  penalty  for  the  perversity,  ignorance,  and  delu.sions 
of  members  of  their  family.  In  such  cases  the  prognosis  varies  according 
to  the  keen  discernment  of  the  physician  and  his  insistence  upon  removal 
of  imfavorable  social  influences  through  such  isolation  as  may  be  reason- 
able and  practicable.  While  patients  are  not  always  ready  to  accept 
at  once  the  wisdom  of  such  advice,  if  presented  firmly  and  tactfully, 
the  difficulties  of  its  execution  often  are  removed. 

PERSONAL  EQUATION  IN  MEDICAL  SUPERVISION 

From  the  foregoing  considerations  it  is  easy  to  comprehend  that  the 
welfare  of  the  patient  is  influenced  to  a  remarkable  extent  by  an  inter- 
ested, painstaking  regard  for  detail  on  the  part  of  the  medical  advaser. 
The  best  results  can  be  obtained  only  through  a  certain  inherent  aptitude 
of  the  physician,  a  devotion  to  the  work  in  which  he  is  engaged,  and 
a  personal  solicitous  interest  in  the  individual.  To  discharge  properly 
the  many  obligations  incident  to  the  care  of  the  consumptive,  and  to 
assume  with  composure  and  confidence  the  anxious,  vexatious  responsi- 
bilities imposed,  the  physician  must  possess  to  an  unusual  degree 
patience,   determination,   vigilance,  sympathy,  tact,  and  enthusiasm. 


FACTORS    PERTAINING    TO   THE    INDIVIDUAL  311 

The  extent  to  which  such  endowment  is  possessed  determines  largely 
the  welfare  of  the  patient  and  frequently  is  sufficient  to  change  impend- 
ing failure  into  ultimate  success. 

CHANGE  OF  SURROUNDINGS  AND  CLIMATE 

As  a  general  rule,  the  chances  for  recovery  are  greatly  enhanced 
if  opportunity  is  afforded  for  suitable  change  of  environment.  Patients 
are  much  less  likely  to  do  well  at  home,  as  the  difficulties  in  maintaining 
a  proper  regime  are  sufficiently  great  to  interfere  with  the  accomplish- 
ment of  the  best  residts,  and  to  suggest  the  impracticability  of  the 
attempt,  when  possible  to  avoid  it.  Not  only  are  the  social  conditions 
non-conducive  to  an  unbroken  period  of  nervous  and  physical  relaxation, 
but  the  incidental  interruptions,  by  friends  and  relatives,  unavoidably 
impair  the  good  effects  of  a  systematic  regime.  The  situation  of  the 
dwelling  with  relation  to  other  buildings  often  is  not  such  as  to  afford 
a  sufficient  amount  of  fresh  air  and  sunshine.  Atmospheric  contami- 
nations may  exist  by  reason  of  smoke,  dust,  and  other  impurities. 
Assuming  an  advantageous  location  of  the  residence,  there  may  be 
lacking  ample  porch  accommodations,  preventing  the  possibility  of 
attaining  rest  and  fresh  air  jointly.  The  perfect  fulfilment  of  these 
cardinal  features  of  management  is  likely  to  be  achieved  only  when 
special  provision  is  made  for  the  reception  of  pulmonary  invalids. 

Due  cognizance  should  be  taken  of  the  value  of  the  psychic  element 
attending  a  change  of  environment.  The  novelty  of  radically  differing 
surroundings  is  a  factor  of  the  utmost  importance  in  inspiring  the 
patient  with  a  degree  of  hope  far  in  excess  of  that  evinced  at  home. 
The  invalid  is  forcibly  impressed  with  the  fact  that  something  definite 
and  tangible  is  being  done  to  promote  recovery,  and  often  an  abiding 
confidence  is  thereby  established.  This  is  especially  likely  to  be  the  case 
if  brought  in  contact  with  others  who,  through  the  force  of  example,  instil 
an  ambition  to  pursue  an  appropriate  routine  and,  through  the  recital 
of  their  favorable  progress,  infuse  transcendent  faith  in  the  attainment 
of  similar  results.  A  consideration  of  no  slight  importance  relates  to 
the  direct  educational  influence  exerted  upon  the  patient  in  properly 
managed  local  institutions.  Residence  in  sanatoria,  even  without  the 
involvement  of  climatic  change,  is  a  factor  of  unquestionable  prognostic 
value. 

Change  of  climate  in  properly  selected  cases,  with  or  without  recourse 
to  sanatorium  control,  is  of  far-reaching  importance  in  the  effort  to 
secure  an  enduring  arrest.  While  improvement  in  many  incipient  ca.ses 
assuredly  may  take  place  by  virtue  of  intelligent  systematic  management 
in  relatively  unfavorable  climates,  the  chances  for  such  happy  results 
are  not  equal  to  those  presented  in  more  healthful  resorts  under  the 
same  conditions  of  management.  There  can  be  no  question  upon  the 
basis  of  actual  experience  that  the  prognosis  is  wonderfully  improved 
by  removal  to  a  suitable  climate.  Not  only  are  the  opportunities  for 
arrest  of  the  tuberculous  process  immeasurably  greater,  but  stranger 
assurances  are  afforded  for  its  enduring  maintenance  upon  the  active 
resumption  of  a  useful  occupation. 


312  DIAGNOSIS    AXD    PROGNOSIS 

CHAPTER  XLIV 
CONSIDERATIONS  PERTAINING  TO  THE  DISEASE 

Much  iniportiiiice  attaches  to  the  history  of  the  present  illness,  the 
physical  signs,  the  evidences  of  apparent  immunity,  the  extent  of  sj-s- 
temic  disturbance,  and  the  development  of  complications. 

HISTORY  OF  PRESENT  ILLNESS 

Rigid  inquiry  concerning  the  early  history  of  the  disease  will  often 
disclose  data  of  vital  prognostic  interest.  The  method  of  onset  may  be 
suggestive  of  the  subsequent  type  and  termination.  Many  cases  with 
an  abrupt  invasion  after  the  manner  of  acute  pneumonic  phthisis  or 
acute  miliary  tuberculosis  may  he  expected  to  pursue  an  exceedingly 
rapid  course,  with  a  correspondingly  unfavorable  prognosis.  When  the 
onset  is  characterized  by  other  acute  manifestations,  at  least  an  inti- 
mation may  be  afforded  concerning  the  clinical  course;  thus  acute  septic 
disturbances,  if  predominating  early  in  the  cUsease,  often  persist  to  the 
very  end.  While  initial  hemorrhages  usually  call  emphatic  attention 
to  the  pulmonary  condition  and  induce  a  more  ready  adaptation  of  the 
invalid  to  a  suitable  environment,  it  cannot  be  assumed  that  the  exist- 
ence of  early  pulmonary  hemorrhage  exerts  any  inherent  influence  upon 
prognosis.  Pulmonary  tuberculosis  supervening  immediately  upon  an 
attack  of  influenza  is  usually  of  serious  prognostic  import.  The  indi- 
vidual resistance  at  such  a  time  is  comparatively  slight,  and  the  disease, 
in  the  larger  number  of  eases,  advances  rapidly  to  destructive  tis- 
sue change  and  pronounced  constitutional  impairment.  Within  certain 
limits  it  is  safe  to  assert  that  the  more  acute  the  onset,  the  less  favorable 
the  prognosis  and  the  more  insidious  the  invasion,  the  greater  likelihood 
of  effecting  an  arrest. 

Exclusive  of  the  manner  of  onset,  a  review  of  the  extent  and  nature 
of  systemic  disturbance  is  also  of  considerable  value  in  establishing  a 
reasonable  prognosis.  The  history  of  progressive  loss  of  weight  and 
strength,  with  fever,  chills,  night-sweats,  and  increasing  dyspnea,  sug- 
gests, of  course,  a  far  less  favorable  prognosis  than  obtains  in  afebrile 
cases  without  constitutional  impairment. 

The  previous  duration  of  the  disease  is  not  without  some  significance, 
although  it  is  scarcely  true  that  the  longer  the  condition  has  persisted, 
the  less  favorable  the  prognosis.  If  the  infection  has  been  of  long 
duration  and  unattended  by  progressive  pulmonary  invasion  or  by 
symptoms  of  severe  uonstitutional  derangement,  it  may  be  assumed  that 
the  invalid  possesses  unusual  powers  of  resistance,  and  that  these  fighting 
qualities,  under  proper  management,  may  be  later  directed  to  a  success- 
ful issue.  After  a  period  of  disastrous  delay,  liowever,  there  inevitably 
must  come  a  time,  soon  for  some,  later  for  others,  and  finaUi/  for  all, 
when  the  patient  becomes  utterly  unable,  even  with  strenuous  efforts 
of  management,  to  display  anything  like  former  combativeness  against 
the  disease.  It  thus  follows  that  while  a  prolonged  duration,  in  the 
absence  of  distinctly  unfavorable  manifestations,  may  be  construed  as 
a  favorable  prognostic  consideration  in  some  cases,  yet  delay  in  the 
adoption  of  rational  management  results  in  a  decided  loss  of  opportunity 
in  the  effort  to  secure  arrest. 


CONSIDERATIONS    PERTAINING    TO    THE    DISEASE  313 


PHYSICAL  SIGNS 

The  physical  signs  are  of  signal  importance  as  indicating  the  area 
of  tuberculous  infection,  the  nature  and  activity  of  the  process,  the 
extent  of  destructive  change,  and  the  amount  of  tissue  fibrosis.  The 
morbid  pulmonary  changes  thus  disclosed,  although  of  essential  value 
in  an  approximate  estimate  of  the  final  results,  are  sometimes  of  far 
less  prognostic  importance  than  the  accompanying  symptoms.  In 
view  of  the  striking  lack  of  conformity  between  the  physical  signs  and 
the  subjective  symptoms,  it  is  apparent  that  the  former  alone  are  quite 
inadequate  for  the  purposes  of  prognosis.  Many  patients  exhibiting 
extensive  acti\'e  areas  of  involvement  display  wonderful  powers  of 
resistance  and  secure  an  ultimate  arrest  of  the  infection.  Others  with 
comparatively  slight  evidence  of  pathologic  change  in  the  lung  never- 
theless decline  rapidly  to  a  fatal  issue,  despite  the  best  conditions  of 
management  and  environment.  The  physical  signs  are  of  especial 
prognostic  value  in  connection  with  the  associated  evidences  of  con- 
stitutional disturbance,  when  their  significance  becomes  of  vital  impor- 
tance. 

The  area  of  involvement,  regardless  of  other  considerations,  is  not 
always  of  vital  prognostic  import,  the  size  of  the  infected  region  being 
of  much  less  moment  than  the  character  of  the  tuberculous  process  and 
its  degree  of  activity.  A  diffused  infiltrative  tubercle  deposit  without 
definite  consolidation,  abundant  moisture,  or  softening  offers  a  far  more 
hopeful  outlook  than  a  circumscribed  area  of  infection  associated  with 
advancing  destructive  change.  The  extent  of  liacillary  distribution  in 
pulmonary  tuberculosis  becomes  of  especial  piognostic  interest  in  pro- 
portion to  the  degree  of  secondary  inflammatory  disturbance  and 
accompanying  degenerative  change.  Other  features  of  prognosis  being 
equal,  it  is,  of  course,  true  that  the  outlook  is  better  among  patients 
exhibiting  comparatively  small  areas  of  infection.  A  limitation  of 
the  disease  at  one  apex  is  of  more  favorable  import  than  a  l)ilaterul 
involvement.  It  is  insisted,  however,  that  efforts  to  forecast  the  future 
of  the  invalid  strictly  according  to  the  boundaries  of  tuberculous  infec- 
tion are  without  warrantable  basis.  Attempts  of  this  kind  represent 
a  profound  misconception  of  the  nature  of  the  various  pathologic  proc- 
esses, the  influence  of  constitutional  symptoms,  and  other  prognostic 
data. 

Chief  importance  attaches  to  the  character  of  the  lesions,  the  activity 
of  the  infection,  and  the  tendency  to  cavity  formation.  Infiltrative 
processes  are  more  susceptible  to  complete  arrest  through  fibrous  tissue 
proliferation  than  are  areas  of  massive  consolidation,  in  which  subse- 
quent softening  with  excavation  is  likely  to  take  place.  In  the  latter 
event  the  constitutional  symptoms  are  often  more  severe,  the  tuber- 
culous extension  rapid,  and  the  course  of  the  disease  comparatively 
short.  In  some  ca.ses,  however,  consolidation,  even  of  an  entire  lobe, 
may  continue  indefinitely  without  resulting  cavity  formation  or  per- 
sisting systemic  disturbance.  A  conspicuous  example  of  this  phe- 
nomenon is  shown  by  the  following  case: 

In  June,  1897,  a  gentleman  of  forty-eight,  a  patient  of  Dr.  Babcock, 
came  to  Colorado,  exhibiting  a  massive  consolidation  of  the  entire  left 
lung  with  abundant  moisture  throughout.  There  were  marked  emacia- 
tion,  physical   exhaustion,   fever,   and   rapid   pulse.     He  returned   to 


314  DIAGNOSIS    AND    PROGNOSIS 

Indiana  in  May,  1903,  thirty  pounds  heavier,  without  fever  or  other 
evidence  of  constitutional  disturbance,  exhibiting  not  the  slightest 
physical  evidence  of  remaining  tuberculous  activity,  although  the  con- 
solidation was  complete  and  the  function  of  the  lung  entirely  suspended. 
He  has  continued  without  retrogression  to  the  present  time. 

While  successful  results  of  this  character  are  sometimes  observed, 
the  prognosis,  as  a  rule,  is  unfavorable  in  cases  of  gross  pulmonary 
consolidation. 

Scattered  areas  of  pneumonic  consolidation  supervening  in  the  course 
of  pulmonary  tuberculosis  are  occasionally  followed  by  apparent  resolu- 
tion, but  softening  and  cavity  formation  are  the  usual  sequela?.  If 
arrest  of  the  tuberculous  process  eventually  takes  place,  there  is  nec- 
essarily an  enduring  loss  of  functional  activity  throughout  the  diseased 
area.  In  some  instances  the  prognosis,  as  a  result  of  the  fimctional 
impairment  and  the  physical  incapacity  of  the  invalid,  relates  chiefly  to 
a  prolonged  period  of  restricted  activity.  Corresponding  to  the  degree 
of  respiratory  limitation,  the  patient  may  either  be  permitted  to  enjoy 
a  useful  career,  or  be  tloomed  to  a  life  of  complete  invalidism. 

The  activity  of  the  infection  is  disclosed  to  a  great  extent  by  the 
amount  of  moisture  within  the  bronchial  tract.  Despite  pronounced 
indications  of  general  improvement,  rather  definite  information  con- 
cerning a  remaining  active  tuberculous  process  is  afforded  by  the  recog- 
nition of  fine  and  medium-sized  moist  rales.  No  tuberculous  deposit 
can  be  regarded  as  arrested  or  even  quiescent  so  long  as  these  physical 
evidences  persist. 

There  is  no  invariable  relation  between  the  state  of  the  tuberculous 
lesions  and  the  amount  of  cough  or  expectoration.  I  almo.st  daily 
observe  patients  exhibiting  moist  rales  upon  examination,  yet  having 
but  slight  cough  without  expectoration.  In  the  presence  of  bubbling 
rales  the  tendency  to  further  extension  of  the  tuberculous  process  is 
greatly  enhanced,  irrespective  of  subjective  symptoms.  Waiving  tem- 
porarily a  consideration  of  other  elements  influencing  prognosis,  it  is 
fair  to  assert  that  the  chances  for  recovery  are  improved  in  proportion 
to  the  diminution  of  moisture  in  the  infected  area.  Prior  to  its  com- 
plete disappearance  favorable  prognostic  indications  consist  of  a  reduc- 
tion in  the  size  of  the  rales,  a  lessening  of  their  distinctly  bubbling 
character,  and  their  non-recognition  save  upon  the  act  of  coughing. 

The  extent  of  tissue  destruction  as  represented  by  pulmonary  exca- 
vation adds  greatly  to  the  danger  of  hemonhage  and  the  likelihood  of 
septic  absorption.  This,  with  the  accdniiianying  evidence  of  advancing 
infection,  constitutes  an  important  tacim  in  prognosis.  In  some  cases 
the  cavity  per  se,  even  if  it  be  of  (•oiisKlcraliJc  size,  may  possess  but  little 
significance  regarding  the  probable  outcome.  If  surrounded  by  indu- 
rated lung  tissue,  it  may  gradually  diminish  in  diameter  through  inter- 
stitial contraction  to  such  an  extent  as  to  prevent  its  further  recognition. 
The  unfavorable  import  to  be  attached  to  cavity  formation  relates  to 
the  rapidity  of  development,  the  progressive  increase  in  size,  the  accom- 
panying moisture,  and  the  subjective  symptoms.  Aside  from  gurgling 
rales  over  the  site  of  the  excavation,  an  indication  of  the  activity  of 
the  infection  is  found  in  the  amount  of  moisture  present  within  an 
adjacent  zone.  Coarse  bubbling  rales  in  close  proximity  to  the  cavity 
suggest  a  further  extension  of  the  destructive  process.  Even  rapid 
cavity  formation  may  not  always  be  construed  as  of  luifavor.ible  import, 


CONSIDERATIONS    PERTAINING    TO   THE    DISEASE  315 

though  this  assuredly  is  the  general  rule.  The  first  clinical  manifesta- 
tions of  general  improvement  are  occasionally  observed  only  after  a 
rapid  excavation  with  elimination  of  innumerable  virulent  bacilli  and 
diminution  of  toxic  absorption.  As  a  general  rule,  the  prognosis  im- 
proves in  proportion  to  the  proliferation  of  fibrous  tissue.  In  excep- 
tional instances  the  fibrosis  assumes  such  undue  prominence  as  to  occasion 
circulatory  embarrassment  through  obliteration  of  the  finer  subdivisions 
of  the  pulmonary  artery.  With  extensive  fibrous  tissue  change  there 
may  result  such  disturbance  of  physiologic  function  as  to  incapacitate 
the  individual  for  an  existence  beyond  the  limits  of  passive  invalidism. 

EVIDENCE  OF  APPARENT  IMMUNITY 

,  The  relative  immunity  of  individuals  to  tuberculous  invasion  is 
of  much  interest  from  a  prognostic  standpoint.  Two  essential  influences 
are  worthy  of  consideration,  i.  e.,  difTerenees  in  the  virulence  of  the 
bacillus  and  in  the  resistance  of  the  host. 

The  former  has  been  demonstrated  by  experiments  upon  animals 
and  by  the  results  of  laboratoiy  investigation.  Cultures  of  tubercle 
bacilli  inoculated  into  guinea-pigs  have  produced  death  of  the  animals 
in  three  or  four  weeks,  while  inoculations  of  similar  animals  with  bacilli 
from  another  source  of  infection  have  been  followed  by  death  only  after 
considerably  longer  intervals,  denoting  a  decided  difference  in  the  viru- 
lence of  the  cultures.  Thus  it  may  be  assumed  that  in  the  human  being 
a  corresponding  variation  of  virulence  may  exist,  and  represent  a  factor 
of  some  importance  in  the  evolution  of  individual  immunity.  Some 
enthusiastic  observers  have  even  attempted  to  forecast  a  prognosis  from 
the  character  of  the  clinical  manifestations  exhibited  by  the  person 
from  whom  a  recent  infection  is  ostensibly  derived.  Thus  a  benign 
type  of  the  disease  is  alleged  to  attend  an  infection  acquired  from  con- 
tact with  invalids  exhibiting  quiescent  tuberculous  processes.  This 
line  of  thought  presupposes  a  predominant  influence  of  the  bacillus 
as  a  factor  in  prognosis,  to  the  exclusion  of  all  considerations  pertain- 
ing to  the  resistance  of  the  host.  Such  conclusions  are  utterly 
at  variance  with  the  results  of  clinical  observation.  In  numerous 
instances  I  have  noted  a  rapid  course  and  a  fatal  termination  of  pulmo- 
nary phthisis  in  the  husband  or  wife,  while  the  infection  of  the  consort 
from  whom  the  disease  was  contracted  remained  inactive  for  years  or 
became  entirely  arrested. 

Aside  from  inherent  differences  as  to  the  virulence  of  the  bacilli, 
a  pronounced  influence  upon  their  virulent  action  is  exerted  by  the 
character  of  the  .soil. 

The  individual  resistance  may  be  active  and  aggressive,  or  the  defense 
of  the  organism  may  be  comparatively  slight.  In  some  people  the  power 
to  withstand  the  bacterial  infection  applies  to  the  destructive  change, 
and  in  others  to  the  accompanying  toxemia.  It  is  well  kndwii  that 
marked  differences  are  exhibited  liy  invalids  in  their  susccjitiliilit y  to 
the  tuberculous  invasion,  and  that  the  prognosis  improves  in  pidiKntidn 
to  the  apparent  resistance.  To  what  extent  in  the  determination  of  the 
resulting  immunity  the  influence  of  the  host  is  exerted  upon  the  bacillus 
and  vice  versa  is  diflicult  of  differentiation. 

The  trend  of  modern  thought  does  not  incline  to  the  recognition 
of  the  bacillus  as  the  factor  of  greater  importance.     Clinical  evidence 


316  DIAGNOSIS    AXD    PROGNOSIS 

as  to  the  determining  influence  of  the  soil  is  demonstrated  in  the  trans- 
formation of  virulent  bacilli  into  microorganisms  of  the  attenuated  type, 
as  a  result  of  progressive  general  improvement.  It  is  not  uncommon 
in  the  observation  of  a  single  case  of  pulmonary  tuberculosis  that  short, 
thin,  bright-staining  bacilli  devoid  of  granulations,  and  characterized 
by  an  even  stain,  are  subsequently  found  to  become  long,  thin,  beaded, 
and  to  stain  unevenly.  The  fact  that  the  attenuated  variety  make  their 
appearance  only  in  proportion  to  the  evidences  of  physical  and  general 
improvement  may  be  construed  as  of  material  significance. 

CHARACTER  OF  SYSTEMIC  DISTURBANCE 

Among  the  subjective  symptoms  endowed  with  variable  degrees  of 
prognostic  significance,  fever  is  by  all  odds  the  most  important.  There 
is  no  single  feature  throughout  the  entire  clinical  course  of  the  disease 
of  more  fateful  import  than  a  persisting  high  temperature  elevation.  As 
previously  explained,  the  true  influence  of  fever  in  a  determination  of 
the  final  result  depends  upon  its  height,  cause,  and  duration,  but  its 
unfavorable  effect  is  exerted  chiefly  by  virtue  of  its  persistency.  While 
fever  may  greatly  modify  the  clinical  course,  its  existence  is  not  always 
precursory  of  disaster.  A  stubborn  temperature  elevation  is  often 
susceptible  of  great  amelioration,  if  not  of  complete  control,  according 
to  the  nature  of  therapeutic  management.  Therefore,  high  fever  must 
not  be  accepted  as  an  element  of  fatal  import  until  its  unyielding  nature 
has  been  demonstrated  by  exhaustive  clinical  effort. 

An  undue  acceleration  of  the  pulse  independent  of  fever  or  other 
obvious  cause  must  always  be  regarded  as  of  unfavorable  moment.  At 
the  time  of  examination  it  is  often  impossible  to  judge  accurately  con- 
cerning the  character  and  rate  of  the  pul.se  by  reason  of  coexisting 
nervous  excitement.  An  inorchnately  rapid  pulse,  occasioned  by  exer- 
cise, mental  emotion,  or  excitement,  is  rarely  an  insuperable  obstacle 
to  arrest,  but  continuous  acceleration,  constituting  a  true  tachycardia, 
is  possessed  of  grave  significance  as  regards  the  remote  prognosis.  While 
less  optimistic  opinions  must  be  rendered  with  reference  to  this  con- 
dition, a  conscientious  application  of  hygienic  principles  of  management 
may  result  in  ultimate  recovery. 

The  degree  of  nutrition  has  been  described  as  a  consideration  of 
momentous  importance.  A  progressive  diminution  of  body  weight, 
despite  the  existence  of  other  features  of  favorable  significance,  must  be 
construed  as  a  factor  of  ill  omen.  However,  in  some  instances  of  exten- 
sive fibroid  change  involving  both  lungs,  with  marked  impairment  of 
function,  a  considerable  loss  of  weight  may  accompany  even  an  entire 
arrest  of  the  tuberculous  infection.  These  cases  are  seldom  observed, 
but  are  conspicuous  on  account  of  the  disparity  between  the  external 
appearance  and  the  physical  signs.  The  fullest  significance  of  emacia- 
tion is  reflected  in  failure  to  respond  to  superalimentation  and  rest. 
Much  more  frec^uently,  however,  is  loss  of  weight  dependent  upon  dimi- 
nution of  appetite  and  disturbances  of  digestion. 

Comparatively  slight  importance  is  attached  to  the  acute  gastric 
and  intestinal  symptoms  resulting  from  an  injudicious  interpretation  of 
the  principles  of  superalimentation.  Digestive  disturbances  occasioned 
by  continuous  dietary  indulgence  must  undoubtedly  influence  prognosis, 
but  the  intelligence  of  the  patient  and  physician  usually  is  sufficient  to 


CONSIDERATIONS    PERTAINING    TO    THE    DISEASE  317 

guard  against  too  frequent  repetition  of  such  disorders.  As  a  feature 
of  prognosis,  the  practical  disadvantage  of  digestive  derangement  con- 
sists of  the  confirmed  loss  of  appetite  and  the  inability,  without  this,  to 
conform  to  a  satisfactory  system  of  dietetics.  A  poor  stomach  repre- 
sents one  of  the  most  serious  obstacles  to  a  successful  issue. 

The  prognosis  is  also  influenced  materially  by  the  physical  findings 
in  the  upper  air-passages,  heart,  liver,  and  kidneys.  As  stated  elsewhere, 
a  passive  congestion  of  the  liver  is  possessed  of  decidedly  unfavorable 
import.  Grave  significance  must  necessarily  be  attached  to  many  foims 
of  kidney  disturbance  which  have  been  described.  Decided  arterioscle- 
rosis invariably  has  an  unfortunate  bearing  upon  prognosis.  The  influ- 
ence of  enteroptosis  and  the  various  psychoneuroses,  together  with  the 
prognosis  of  laryngeal  tuberculosis,  pleurisy  with  effusion,  empyema, 
pneumothorax,  and  other  complications,  will  be  discussed  in  their  appro- 
priate place. 

The  cough  is  of  but  slight  interest  as  a  feature  of  prognosis.  Exten- 
sive bronchial  irritation  may  exist  even  in  the  presence  of  satisfying 
gain  in  the  pulmonary  condition,  but  subsidence  of  cough  and  expectora- 
tion at  such  a  time  adds  hopeful  color  to  the  permanency  of  the  improve- 
ment. The  cough  may  be  distinctly  disadvantageous  on  account  of 
the  resulting  exhaustion,  disturbance  of  sleep,  and  the  production  of 
reflex  vomiting.  Generally  speaking,  however,  it  is  idle  to  suggest  a 
relation  Isetween  the  degree  of  cough  and  the  probable  outcome. 

The  number  of  bacilli  demonstrable  in  the  expectoration  is  not  always 
endowed  with  especial  prognostic  import.  A  reasonable  construction 
to  be  placed  upon  their  relative  frequency  is  to  the  effect  that  their 
gradual  diminution  constitutes  a  favorable  indication,  particularly  in 
connection  with  their  increasing  attenuation. 

In  view  of  the  encouraging  outlook  for  the  pulmonary  invalid  of 
to-day,  as  compared  with  the  pessimistic  attitude  of  the  profession  in 
the  past,  it  will  be  of  interest  to  read  the  following  from  an  address 
delivered  by  Dr.  Oliver  Wendell  Holmes  in  1867  before  the  Harvard 
Medical  School.  These  words  by  one  universally  revered  by  the  medical 
profession  are  introduced  largely  because  of  the  singular  beauty  of 
expression.  In  his  simple  and  inimitable  style  he  depicts  the  old-fash- 
ioned manner  of  medical  instruction  by  presenting  to  one's  imagination 
a  worthy  physician  making  his  round  of  visits  accompanied  by  his  one 
student.  "They  jogged  along  the  bridle  path  on  their  horses  until  they 
came  to  a  lowly  dwelling.  They  sat  a  while  with  a  delicate  looking  girl 
in  whom  the  ingenuous  youth  takes  a  special  interest.  .  .  .  and  so  they 
left  the  house. 

"What  thinkest  thou,  Luke,  of  the  maid  we  have  been  visiting?" 
"She  seemeth  not  much  ailing,  Master,  according  to  my  poor  judgment. 
For  she  did  say  she  was  better.  And  she  had  a  red  cheek  and  a  bright 
eye,  and  she  spake  of  being  soon  able  to  walk  unto  the  meeting,  and  did 
seem  greatly  hopeful,  but  spare  of  flesh,  methought,  and  her  voice 
something  hoarse,  as  of  one  who  hath  a  defluxion,  with  some  small 
coughing  from  a  cold,  as  she  did  say.  Speak  I  not  truly,  Master,  that 
she  will  be  well  speedily?" 

"Yea,  Luke,  I  do  think  she  shall  be  well,  and  mayhap  speedily. 
But  it  is  not  here  with  us  she  shall  be  well.  For  that  redness  of  the 
cheek  is  but  the  sign  of  the  fever,  which  after  the  Grecians,  we  do  call 
the  hectical;  and  that  shining  of  the  eyes  is  but  a  sickly  glazing,  and 


318  DIAGNOSIS    AND    PROGNOSIS 

they  which  do  every  day  get  better  and  likewise  thinner  and  weaker 
shall  find  that  way  leadeth  to  the  church-yard  gate.  This  is  the  malady 
which  the  ancients  did  call  tabes,  or  the  wasting  disease,  and  some  do 
name  the  consumption.  A  disease  whereof  most  that  fall  ailing  thereof 
do  perish.  This  Margaret  is  not  long  for  earth,  but  she  knoweth  it  not, 
and  still  hopeth." 

The  logic  of  latter-day  experience  affords  irrefutable  testimony 
that  save  under  exceptional  conditions,  no  given  case  of  tuberculosis 
should  be  pronounced  absolutely  hopeless.  Far-advanced  cases  of 
consumption  exhibiting  marked  constitutional  disturbances  and  exces- 
sive tissue  destruction  are  sometimes  capable  of  undergoing  a  complete 
and  enduring  arrest.  Clinicians  whose  experience  has  been  confined  to 
the  observation  of  incipient  cases  in  sanatoria  may  not  be  inclined  to 
accept  this  statement,  but  those  who  have  enjoyed  the  varied  experience 
rendered  possible  in  health  resorts  will  verify  such  a  conclusion.  A  few 
illustrative  cases  are  presented  to  show  precisely  what  is  meant  by 
reported  recoveries  of  cases  at  first  considered  to  be  hopeless. 

Case  1. — A  woman,  twenty-four  years  old,  consulted  me  ilay  24, 
1902,  the  day  of  arrival  in  Colorado,  eight  months  after  recognized 
symptoms  of  tuberculosis.  There  had  been  progressive  rapid  failure 
from  the  beginning,  and  a  loss  of  over  fifty  pounds  of  weight.  She  had 
experienced  chills  daily,  with  severe  night-sweats,  the  average  afternoon 
temperature  being  from  102°  to  103°  F.  The  cough  was  excessive  and 
the  expectoration,  which  contained  numerous  bacilli,  amounted  to  four 
ounces  during  the  twenty-four  hours.  Dyspnea  was  marked,  and  the 
pulse  ranged  from  120  to  140.  Upon  examination  there  was  found 
extensive  infection  of  both  lungs;  in  the  left,  signs  of  consolidation  with 
fine  moist  rales  after  cough  from  the  apex  to  the  fourth  rib  in  front ,  and 
to  the  very  base  behind;  in  the  right,  numerous  fine  clicks  from  the 
second  interspace  to  the  base  in  front,  and  from  the  middle  of  the  inter- 
scapular space  to  the  ba.se  in  the  back. 

On  account  of  the  extensive  pulmonary  involvement,  the  great  emaci- 
ation, the  long-continued  sepsis,  and  an  irritable,  nervous  temperament 
an  absolutely  unfavorable  prognosis  was  rendered.  The  urgency  of 
the  case  was  such  that  cardiac  stimulation  was  employed  constantly, 
and  upon  several  occasions  I  was  constrained  to  believe  that  she  would 
not  survive  twenty-four  hours.  With  a  beginning  diminution  of  fever 
and  circulatory  disturbance,  at  the  end  of  six  weeks  there  gradually 
developed  increase  of  appetite,  cUgestion,  strength,  and  weight,  with 
lessening  of  cough  and  expectoration.  Following  a  progressive  improve- 
ment during  a  period  of  two  years  the  patient  was  discharged  as  an 
arrested  case  and  permitted  to  return  home,  having  gained  forty-three 
pounds  in  weight.  There  was  no  cough  or  expectoration  and  the  pulse 
was  uniformly  under  80.  Physical  examination  at  that  time  disclosed 
no  evidences  of  existing  tuberculous  infection.  There  had  resulted, 
however,  extensive  proliferation  of  fibrous  tissue  throughout  the  infected 
areas,  giving  rise  to  appreciable  changes  in  the  pitch  and  quality  of  respi- 
ratory sounds  without  rales. 

She  has  remained  at  home  over  five  j'ears,  and  last  advices  show 
no  evidence  of  retrogression,  in  spite  of  the  fact  that  she  has  given  birth 
to  two  children  since  she  left  Colorado. 

Case  2. — A  woman,  thirty-five  years  old.  arrived  in  Colorado  in 
April,  1899,  nearly  five  years  after  the  recognized  onset  of  her  pulmonary 


CONSIDERATIONS    PERTAINING    TO   THE    DISEASE  319 

infection.  There  had  been  a  loss  of  fifty-five  pounds  in  weight;  the 
cough  was  distressing  and  paroxysmal,  with  daily  high  fever  and  a  pulse 
varying  from  130  to  160  at  rest.  She  was  unalsle  to  sit  up  in  bed 
and  for  weeks  nourishment  had  been  taken  through  a  tube.  Upon 
examination  there  were  found  signs  of  extensive  active  tuberculous 
infection  of  each  lung;  in  the  right  upper  front  a  cavit}'  the  size  of  a 
small  orange,  surrounded  by  consolidation  which  extended  to  the  fourth 
rib,  and  in  the  back  to  the  lower  edge  of  the  scapula;  in  the  left,  consoli- 
dation from  the  apex  to  the  third  rib  and  to  the  middle  of  the  inter- 
scapular space.  Throughout  this  entire  region  moist  bubbling  rales  were 
recognized  on  easy  respiration. 

A  hopeless  prognosis  was  made  without  qualification.  The  family 
physician  who  accompanied  her  to  Colorado  stated  that  she  could  survive 
but  a  week  or  ten  days  at  the  most.  She  was  kept  in  bed  in  the  open  air 
for  nearly  six  months,  with  licjuid  nourishment  and  nutritive  enemata 
for  two  months.  She  remained  under  my  constant  oliservation  for  two 
years,  during  which  time  she  exhibited  a  slow,  but  remarkable,  improve- 
ment. During  the  first  six  months  in  bed  she  gained  fifty  pounds  in 
weight,  with  a  corresponding  improvement  in  her  general  and  pulmo- 
nary conditions.  At  the  time  she  was  discharged  there  was  a  gain  of 
nearly  seventy  pounds  in  weight,  but  with  a  slight  persisting  bronchial 
cough.  There  was  no  moisture  recognized  upon  physical  examination, 
though  fibrous  tissue  changes  were  cjuite  pronounced.  She  moved  to  a 
remote  part  of  the  State  and  continued  to  maintain  her  improvement 
until  she  cUed,  two  years  ago,  of  acute  appendicitis. 

Case  3. — A  woman,  twenty-nine  years  old,  arrived  in  Colorado 
February,  1898,  two  years  after  developing  pulmonary  tuberculosis. 
During  this  period  she  progressively  declined  in  all  respects.  Theie 
were  great  emaciation,  daily  elevation  of  temperature,  weak,  rapid,  and 
irregular  pulse,  chstressing  paroxysmal  cough,  and  copious  exijectora- 
tion  with  very  numerous  bacilli.  Examination  disclosed  evidence  of 
an  active  process  involving  a  large  portion  of  each  lung.  In  the  upper 
right  lung  in  front  there  was  a  cavity  the  size  of  an  orange,  in  the 
midst  of  an  area  of  consolidation,  with  numerous  bubbling  rales  from 
the  apex  to  the  fourth  rib,  and  in  the  back  from  the  apex  to  the  very 
base.  On  the  left  side  there  was  consolidation  with  moist  rales  from 
the  apex  to  the  third  rib.  Moisture  was  recognized  in  the  left  axilla, 
and  in  the  back  from  the  apex  to  the  lower  third  of  the  interscapular 
space. 

On  account  of  the  exten.sive  pathologic  change,  pronounced  dyspnea, 
irritable  pulse,  hysteric  temperament,  poor  appetite,  and  frequent 
vomiting,  an  ultimately  hopeless  prognosis  was  entertained  without 
reserve,  which  opinion  was  indorsed  by  Dr.  Babcock,  who  saw  the 
patient  shortly  after  her  arrival  in  Denver.  She  has  remained  under 
my  personal  oljservation  during  a  period  of  ten  years.  During  the  first 
three  years  very  little  change  was  noted,  either  in  the  general  state  or 
in  the  condition  of  the  lungs.  The  cough  was  frequent  and  exhausting, 
expectoration  copious,  and  bacilli  numerous.  During  the  fourth  year 
a  beginning  improvement  was  ob.served  in  the  genei-al  condition,  the 
physical  signs  remaining  practically  stationary.  D\iring  the  fifth  year 
a  gain  of  fifty  pounds  was  made  in  weight,  followed  by  an  astonishing 
improvement  in  every  respect.  During  the  past  five  years  she  has 
maintained  an  excellent  nutrition  and  gained  remarkably  in  strength. 


320  DIAGNOSIS    AND    PROGNOSIS 

For  nearly  four  years  there  have  been  no  bacilli  found  in  the  sputum 
after  numerous  examinations.  There  is  a  persisting  bronchial  cough 
at  intervals,  with  occasional  expectoration.  The  examination  of  the 
chest  shows  no  indication  of  an  existing  tuberculous  process,  although 
fibroid  changes  are  reachly  detected. 

Cose  4. — A  young  man,  aged  nineteen,  consulted  me  in  May,  1899, 
his  illness  having  developed  ten  months  previously  as  an  acute  pneu- 
monia involving  the  major  portion  of  the  left  lung.  The  patient  was 
sent  originally  to  Las  ^'egas,  New  Mexico,  in  company  with  a  physician 
and  trained  nurse,  and  two  months  later  to  Arizona,  Koch's  tuberciJin 
being  used  dail.v  for  a  prolonged  period.  Following  an  initial  gain  while 
in  the  Southwest  there  ensued  a  persistent  elevation  of  temperature, 
loss  of  weight  and  strength,  followed  by  several  recurring  hemorrhages. 
Upon  arrival  in  Colorado  there  was  a  loss  of  thirty-two  pounds  in  weight, 
the  temperature  was  104°  F.  in  the  afternoon,  and  the  pulse  rarely  below 
120.  Numerous  bacilli  were  found  in  the  sputum.  There  were  signs 
of  massive  consolidation  in  the  left  front  from  the  apex  to  the  fifth  rib, 
with  moist  rales  throughout,  and  semidry  clicks  in  the  left  axilla.  In 
the  back,  bubbling  rales  were  heard  to  the  very  base,  with  an  area  of 
well-defined  consolidation  extending  from  the  apex  to  the  middle  of  the 
interscapular  space.  On  the  right  side  there  was  slight  consolidation  at 
the  apex,  with  moist  rales  to  the  second  rib,  and  scattered  areas  of  infil- 
tration with  moisture  throughout  the  front.  Fine  clicks  were  heard  in 
the  right  interscapular  space. 

In  view  of  the  age,  the  active  advanced  process  in  one  lung,  the  more 
recent  invasion  of  the  other,  the  hemorrhagic  tendency,  persisting  faver, 
and  rapid  pulse,  the  prognosis  could  scared}'  l^e  other  than  imfavorable. 
There  developed,  however,  a  gradual  resolution  of  the  consolidated 
areas,  and  a  lessened  activity  of  the  tuberculous  process,  as  shown  by 
the  slighter  amount  of  moisture,  chminution  of  cough  and  expectoration, 
fewer  bacilli,  ami  incipase  of  weight  and  strength.  Three  and  a  half 
years  ago,  aftei-  tnc  years'  con.stant  mechcal  observation,  the  patient  had 
gained  nearly  sixty  pmmds,  and  there  was  entire  absence  of  cough  and 
expectoration.  Examination  of  the  chest  failed  to  disclose  any 
tuberculous  activity  whatever,  there  remaining  only  a  somewhat  pro- 
longed high-pitched  expiration,  tubidar  in  quality  at  the  left  apex,  with- 
out moisture.  During  the  past  three  years  he  has  resided  much  of  the 
time  in  Illinois.  At  present,  nearly  nine  years  after  coming  under  my 
observation,  the  arrest  is  complete. 

Case  5. — A  boy,  nine  years  old,  arrived  in  Colorado  June  1,  1903, 
exactly  three  months  after  the  development  of  acute  bronchitic  symp- 
toms. Following  the  initial  onset  he  remained  eight  weeks  in  bed  with 
a  persisting  fever  and  moderate  cough.  At  the  end  of  two  months, 
accompanied  by  his  parents  and  family  physician,  he  went  to  New 
Mexico,  remaining  thirty  da3-s.  During  this  period  there  had  been 
a  progressive  rapid  decline.  At  the  time  I  saw  him  he  was  greatly 
emaciated,  weighing  exactly  fifty  pounds.  His  average  afternoon 
temperature  was  101.5°  F.;  there  was  marked  dyspnea  on  exertion,  the 
appetite  was  exceedingly  poor,  pulse  124,  and  there  was  a  persi.sting  cough 
without  expectoration.  There  were  signs  of  con.solidation  throughout  the 
entire  left  lung,  with  moist  rales  upon  easy  respiration  from  the  apex 
to  base,  front  and  back. 

In  view  of  the  age,  the  histor}-  of  the  development  of  an  idiopathic 


CONSIDERATIONS    PERTAINING    TO   THE    DISEASE  321 

pleurisy,  undoubtedly  tuberculous,  the  continued  fever,  the  great 
emaciation,  and  physical  signs,  an  unfavorable  prognosis  was  rendered. 
The  exclusive  care  of  the  child  was  committed  to  a  trained  muse,  and 
an  unbroken  regimen  was  maintained  for  a  period  of  two  years  and  one 
month.  During  this  time  the  child  exhibited  most  remarkable  improve- 
ment in  spite  of  the  fact  that  at  the  end  of  four  months  he  contracted 
a  typhoid  fever  which  was  of  eight  weeks'  duration,  and  was  followed 
in  the  second  year  by  an  acute  fulminating  appendicitis,  operated 
during  the  first  twenty-four  hours.  He  was  discharged  as  cured  in 
June,  1905,  there  being  not  the  slightest  trace  of  moisture  recognized 
after  repeated  examinations  of  the  chest,  although  fibroid  tissue  pro- 
liferation was  extensive.  His  general  condition  was  excellent  in  all 
respects,  his  weight  approaching  eighty  pounds.  He  has  remained 
well  ever  since. 

Case  6. — A  man,  forty-one  years  old,  came  to  Colorado  in  September, 
1904,  nine  months  after  an  acute  pneumonia,  which  was  followed  by 
severe  persisting  cough  and  continued  fever  with  night-sweats.  In  the 
mean  time  he  had  experienced  a  severe  hemorrhage  and  lost  much 
weight  and  strength.  The  sputum  had  been  loaded  with  bacilli.  He 
had  gained  eighteen  pounds  in  a  well-known  health  resort,  but  exhibited 
persisting  elevation  of  temperature,  with  occasional  chills  and  severe 
sweats.  Although  remaining  in  bed  during  day  and  night  for  months, 
there  was  subsequent  loss  of  weight,  with  increased  cough  and  expec- 
toration. The  condition  of  the  patient  was  pronounced  entirely 
hopeless  by  an  eminent  physician.  Upon  arrival  in  Colorado  examina- 
tion of  the  chest  disclosed  extensive  active  tuberculous  infection  of 
each  lung.  On  the  right  side  moist  rales  were  heard  in  front  to  the 
third  rib,  and  in  the  back  from  the  apex  to  the  very  base.  On  the  left 
side  there  was  well-marked  consolidation  in  the  upper  portion,  with 
but  slight  moisture  in  front,  but  with  coarse  rales  in  the  back  from  the 
apex  to  the  lower  angle  of  the  scapula. 

A  further  decline  was  exhibited  during  several  weeks.  The  tem- 
perature was  constantly  elevated,  chills  and  night-sweats  were  frequent, 
and  there  resulted  greater  loss  of  flesh  and  strength.  The  cough  was 
extremely  distressing,  the  expectoration  copious,  containing  numerous 
bacilli,  the  temperament  markedly  nervous,  the  patient  apprehen.sive 
and  discouraged.  The  active,  widely  disseminated  tuljerculous  infec- 
tion, the  unmistakable  evidence  of  sepsis,  impaired  digestion  with 
entire  absence  of  appetite,  the  weak  and  rapid  pulse,  and  the  general 
prostration  were  sufficient  to  justify,  almost  without  reserve,  an  unfavor- 
able prognosis. 

After  several  months  a  gradual  improvement  was  observed  which 
has  continued  without  interruption.  In  September,  1905,  one  year 
after  coming  West,  there  was  but  little  or  no  expectoration,  fever  had 
been  absent  several  months,  a  gain  of  forty-five  pounds  in  weight  had 
been  established,  and  the  pulse  was  uniformly  of  good  character.  At 
the  present  time  it  is  impossible  to  discover  any  physical  signs  attrib- 
utable to  an  existing  tuberculous  process,  no  moisture  being  recognized 
after  careful  exploration,  although  fibrous  ti.ssue  change  is  marked. 
The  patient  has  engaged  in  an  arduous  legal  practice  in  an  unfavorable 
climate  during  the  past  two  years,  devoting  the  summer  season  to  rest 
and  recreation  in  the  mountains  of  Colorado.  At  the  time  of  his 
resumption  of  work  examinations  of  the  sputum  failed  to  disclose  the 


322  DIAGNOSIS    AND    PROGNOSIS 

presence  of  bacilli.  They  have  been  discovered  at  intervals  since  then, 
but  not  invariably. 

Case  7. — A  young  lady,  eighteen  years  old,  consulted  me  in  June, 
1896,  immediately  upon  coming  to  Colorado.  Her  illness  was  of  one 
and  one-half  years'  duration,  during  which  time  she  had  spent  several 
months  in  the  White  Mountains  and  in  Asheville.  There  were  great 
emaciation  and  pallor,  dyspnea  upon  the  slightest  exertion,  nau.sea 
and  daily  vomiting  with  diarrhea,  pulse  120  to  130  at  rest,  cough 
exceedingly  severe,  expectoration  purulent  and  copious.  Upon  exami- 
nation the  entire  left  lung  was  found  to  be  involved.  There  were  signs 
of  pronounced  consolidation  throughout,  coar.se  bubbling  rales  on 
easy  breathing  from  apex  to  base,  front  and  back,  with  a  cavity  nearly 
the  size  of  a  fist  in  the  front  of  the  left  upper  lung. 

There  was  nothing  in  the  history  or  condition  to  furnish  a  warrant- 
able basis  for  the  slightest  encouragement.  Her  age  was  against  her, 
she  was  profoundly  septic,  and  her  powers  of  resistance  were  evident!}^ 
exhausted.  Cavity  formation  had  already  taken  place,  and  softening 
was  rapidly  going  on  in  a  lung  partially  consolidated  from  apex  to  base. 
She  has  remained  under  my  observation  during  the  ensuing  ten  and 
one-half  years.  Without  entering  upon  a  tedious  recital  of  her  detailed 
progress  I  will  state  that  during  the  greater  portion  of  this  period  she 
conformed  to  a  strict  regime.  Resulting  impro\ement  was  noted  from 
time  to  time,  despite  the  fact  that  her  circumstances  were  limited  and 
only  absolute  necessities  permitted.  Her  eight  years  of  unremitting 
effort  and  patience  sufficed  to  bring  about  a  complete  arre.st.  At  that 
time  there  was  but  little  cough,  and  the  expectoration  essentially 
bronchial  in  character.  She  had  gained  fortj'-three  pounds  in  weight, 
had  shown  no  constitutional  .symptoms  for  one  or  two  years,  and  the 
examination  of  the  chest  revealed  no  evidence  of  existing  tuberculous 
activity.  Examination  of  the  sputum  was  entirely  negative.  She 
was  married  to  an  army  officer  verj'  shortly  afterward,  and  for  over 
a  year  led  the  gay  and  strenuous  social  life  incident  to  a  military  post 
in  close  proximity  to  a  large  city.  At  the  time  of  her  departure  for 
the  Philippines  I  was  privileged  to  make  a  carefid  physical  exami- 
nation. In  spite  of  her  late  hours  of  social  chssipation  it  was  found 
that  there  had  developed  no  renewed  activity  of  her  former  infection. 
A  large  cavity  persisted  in  the  upper  left  front  without  moisture.  No 
rales  could  be  heard  in  any  portion  of  the  lung,  which,  through  the 
lapse  of  yeai's,  was  found  to  have  undergone  extensive  fibrosis.  There 
was  occasional  cough,  but  the  sputum  was  subjected  to  examination 
with  continued  negative  results. 

In  connection  with  the  foregoing  reports  there  are  several  important 
facts  to  be  borne  in  mind:  (1)  That  these  cases  are  selected  merely 
to  illustrate  the  possibUit;/  of  arrest  in  far-advanced  cases,  and  that 
other  instances  of  improvement  equally  striking  can  be  cited.  (2) 
That  the  cases  here  described  were  considered  without  exception, 
by  other  physicians  and  by  myself,  as  being  utterly  hopeless  by  virtue 
of  every  consideration  which  ordinarily  influences  prognosis.  (3)  That 
these  patients  have  not  simply  undergone  improvement  with  the 
ultimate  outcome  as  yet  uncertain,  but,  in  the  proce.ss  of  years,  have 
secured  a  complete  arrest  of  the  tuberculous  trouble,  with  entire  absence 
of  physical  signs,  sputum,  and  bacilli,  and  restoration  to  former  useful- 
ness and  activity.   (4)  That  the  necessity  for  the  practice  of  strict  economy 


CONSIDERATIONS    PERTAINING    TO   THE    DISEASE  323 

has  been  no  insuperable  barrier  to  the  acquirement  of  complete  arrest 
in  a  suitable  climate  under  a  proper  regime.  (5)  No  claim  is  made 
that  the  results  obtained  were  referable  entirely  to  climatic  influences. 
It  is  contended,  however,  that  such  I'esults  in  equally  desperate  cases 
are  impossible  of  attainment  in  what  may  be  regarded  as  relatively 
unfavorable  climates,  no  matter  how  perfect  the  regime.  (6)  No 
special  methods  of  treatment  were  employed  other  than  those  familiar 
to  every  physician  of  experience  in  the  management  of  pulmonary 
tuberculosis.  (7)  No  credit  for  results  obtained  is  assumed  other  than 
that  which  may  relate  to  an  unremitting  personal  attention  to  detail, 
and  an  adaptation  of  means  to  ends  at  times  somewhat  radical.  (8) 
No  case  is  here  reported  that  is  not  entirely  subject  to  confirmation 
by  the  attending  physicians,  whose  names  are  not  cited  in  the  report. 

As  logical  conclusions  from  such  results  it  may  be  stated,  fii-st, 
that  no  physician  can  assume  with  positiveness  to  pronounce  death 
sentence  upon  any  case,  no  matter  how  desperate  the  apparent 
extremity.  Second,  that  each  case  strictly  on  its  merits  is  entitled 
to  a  determined,  painstaking,  and  aggressive  effort  to  secure  arrest. 
It  follows  that  while  the  rich  are  abundantly  able  to  combat  the  disease 
through  such  means  as  their  medical  advisers  may  counsel,  the  poor, 
deprived  of  such  advantages,  are  justly  entitled,  at  the  hands  of  the 
State,  to  adequate  hospital  provision  in  an  effort  to  preserve  life,  rather 
than  to  be  instructed  merely  as  to  the  proper  method  of  passing  their 
remaining  days. 


PART  V 
COMPLICATIONS 


INTRODUCTION 


In  a  book  of  this  character  it  is  particuhirly  desirable  to  review 
the  various  complications  observed  in  the  course  of  pulmonary  tubercu- 
losis in  the  light  of  their  clinical  significance.  It  is  not  designed  to 
limit  the  consideration  of  complications  to  tubei'culous  infections  of 
other  organs  or  remote  parts  of  the  bod}',  but  to  include,  as  well,  the 
intercurrent  non-tuberculo\is  affections  which  exert  a  modifying  influ- 
ence upon  prognosis.  From  a  practical  standpoint  the  coexisting  tuber- 
culous processes  in  other  regions  are  of  especial  importance  and  will 
be  considered  in  some  detail. 

Tubercle  bacilli  may  be  chstributed  to  various  portions  of  the 
human  system  through  the  medium  of  the  blood-stream;  to  the  pleura, 
pericardium,  lymphatic  glands,  and  certain  other  regions  through  the 
lymph-channels;  to  the  pharynx,  stomach,  and  intestines  through  the 
process  of  ingestion;  and  to  the  larynx,  in  some  instances,  through 
direct  contact  with  the  expectoration.  In  the  following  consideration 
of  coexisting  tuberculous  infections  the  grouping  of  the  various  com- 
plications is  attempted  as  far  as  practicable  in  accordance  with  their 
supposed  pathogenesis.  Through  the  agency  of  the  circulation  as  a 
route  of  distribution  the  bacilli  are  deposited  not  only  in  remote  and 
widely  separated  regions  sometimes  involving  an  entire  organ  or  part 
of  an  organ,  but  also  are  disseminated  throughout  the  body.  The 
general  distribution  of  the  bacilli  by  the  blood-stream  gives  rise  to  the 
clinical  recognition  of  what  is  known  as  acute  miliary  tuberculosis. 


SECTION    I 
Acute  Miliary  Tuberculosis 


C'H.XPTER  XLV 
GENERAL  CONSIDERATIONS 

This  condition  is  characterized  by  the  presence,  in  an  infected 
organ  or  in  many  organs,  of  innumerable,  grayish-red  tubercles,  the 
size  of  a  millet-seed,  which  are  evidently  of  simultaneous  deposit  and 
exhibit  the  same  degree  of  development.     The  present  clear  conception 


GENERAL   CONSIDERATIONS  325 

of  the  etiology  of  miliary  tuberculosis  has  been  afforded  as  a  result  of 
the  admirable  work  of  Buhl,  Sir  Astley  Cooper,  Weigert,  Benda,  Pon- 
fick,  Simmonds,  Cornet,  Engel,  Heller,  Eichhorst,  and  others. 

Sir  Astley  Cooper  recognized  the  existence  of  tuberculosis  of  the 
thoracic  duct  in  1798.  Tubercles  have  since  been  found  in  the  duct 
by  Ponfick,  Weigert,  Koch,  Meisels.  Brasch,  Hanau,  Sigg,  and  Benda. 

Weigert  demonstrated  the  existence  of  tuberculosis  of  the  blood- 
vessels and  its  association  with  miliary  tuberculo.sis. 

Tubercle  bacilli  were  found  in  the  blood  by  Baumgarten,  Weichsel- 
baum,  Meisels,  Lustig,  Kutimoyer,  and  Sticker. 

Tuberculosis  of  the  veins  was  described  by  Miigge,  Schuchardt, 
Bergkammer,  Hau.ser,  Meyer,  Will,  Heller,  Brasch,  Banti,  Schmorl, 
Kockel,  and  others  (Cornet). 

From  the  reports  of  these  men  it  has  been  definitely  established 
that  miliary  tuberculosis  can  result  only  from  the  distribution 
of  bacilli  through  the  circulation,  and  that  these  microorganisms 
always  gain  entrance  to  the  blood-stream  from  a  preexisting 
degenerative  tuberculous  focus,  although  the  latter  is  sometimes 
almost  impossible  of  detection.  They  have  shown  that  a  genuine 
tubercle  deposit  may  take  place  in  the  arteries,  veins,  and  tho- 
racic duct  as  a  result  of  the  peripheral  extension  of  adjacent 
tuberculous  foci.  In  some  cases  a  thickening  and  obliteration  of  the 
finer  arteries  and  veins  accompanies  the  tuberculous  extension,  while 
in  others,  with  or  without  perforation,  the  bacilli  are  permitted  to  enter 
the  circulating  fluid  through  degeneration  of  tubercles  in  the  wall  of 
the  arteries,  veins,  or  thoracic  duct.  It  has  been  demonstrated  that 
the  bacilli  do  not  multiph'  in  the  blood.  The  primary  source  of  infection 
may  be  found  in  a  caseating  nodule  in  the  lungs,  or  in  a  tuberculous 
focus  in  the  lymphatic  glands,  the  genito-urinary  system,  bones  or 
joints,  pleura,  intestines,  or  peritoneum. 

Longcope,  in  a  reported  analysis  of  thirty  cases  of  generalized 
tuberculosis  with  aspecial  reference  to  the  thoracic  duct  as  a  site  of 
localized  infection,  introduces  interesting  data  pertaining  to  the  fre- 
quency of  such  involvement  in  cases  of  the  more  acute  type,  in  asso- 
ciation with  a  generally  disseminated  tubercle  deposit  in  the  various 
organs.  In  subacute  cases  the  duct  was  rarely  involved,  and  in  chronic 
cases  not  at  all. 

It  is  easy  to  understand  that  the  precise  distribution  of  bacilli  to 
various  parts  of  the  body  must  correspond  to  their  point  of  entrance 
into  the  circulation  according  to  the  site  of  vessel-wall  infection.  If 
the  bacilli  only  penetrate  comparatively  small  aiierial  luanches,  the 
resulting  miliary  deposit  will  he  confined  to  the  parts  thus  supplied. 
In  the  event  of  "their  entrance  iiitd  tlie  pulmonary  vein,  the  distribution 
takes  place  throughout  the  sysiemic  circulation  from  the  aorta  to  tlie 
smallest  arterial  branches.  ^\  heii  the  bacilli  are  conveyed  to  the  lungs 
via  the  lesser  circulation,  these  organs  act  more  or  less  as  a  filter,  and 
become  diffusely  studded  with  miliarj'  tubercles. 

Manifestly,  the  oiJiioituinties  for  miliary  infection  should  obtain 
especially  in  cases  of  extensive  pulmonary  tuberculosis,  and  in  this 
disease  a  general  tubercle  deposit  occasionally  supervenes.  In  some 
eases  the  pulmonary  involvement  is  quite  insignificant,  suggesting 
the  possibility  of  its  non-relation  to  the  development  of  the  miliary 
infection.      While  pulmonary   tuberculosis  is  an    important    etiologic 


326  COMPLICATIONS 

factor  in  the  production  of  miliary  tuberculosis,  comparatively  few- 
cases  of  consumption  are  complicated  by  tliis  condition.  That 
miliary  involvement  is  not  of  more  common  occurrence  in  the 
course  of  pulmonary  tuberculosis  has  been  the  occasion  of  con- 
siderable comment.  Certain  it  is  that  the  clinical  manifestations 
of  miliary  tubercidosis  are  observed  much  less  often  than  woidd  be 
supposed  in  view  of  the  unusual  opportunities  for  general  infection. 
This  occurs  more  frequently  in  early  years  than  in  adult  life. 

Miliary  tuberculosis  has  been  reported  by  some  observers  to 
follow  frequently  the  absorption  of  infected  lymphatic  glands  or 
the  exudate  of  tuberciUous  pleurisy  or  peritonitis.  From  the 
observation,  however,  of  a  large  number  of  cases  of  this  description 
I  recall  but  few  instances  of  sub.sequent  miliary  involvement.  I  have 
noted  manj^  times,  however,  the  development  of  miliary  tuberculosis 
in  pulmonary  invalids  who,  though  well  nourished,  were  suffering  from 
profound  emotional  disturbance.  Individuals  of  decidedly  ner\-ous  tem- 
perament are  especially  prone  to  this  condition,  particularly  if  subjected 
for  prolonged  periods  to  either  depressing  or  exciting  influences.  I  recol- 
lect, in  particular,  a  young  man  with  arrested  pulmonary  infection  of 
over  a  year's  standing,  in  excellent  nutrition,  and  presenting  every 
physical  indication  of  perfect  health,  who  developed  a  miliary 
infection  tnlldwnii:  -cvcial  nmnths  of  mental  perturbation  as  a  result 
offinaiM  i.il  all. I  >|iiiiir~iir  I  iiil.anassment.  My  attention  has  been  called 
to  the  snnii'wha.t  miu-iial  lic(iueiicy  of  miliary  tuberculosis  in  alcoholic 
individuals,  or  in  those  previously  accustomed  to  such  overindulgence. 

The  structural  formation  and  development  of  tidjercle  have  been 
discussed  in  a  preceding  chapter.  The  clinical  symptoms  of  general 
miliary  tuberculosis  are  variable  to  an  extraordinary  degree.  Notwith- 
standing the  remarkable  diversity  of  clinical  manifestations  common  to 
this  disease,  it  is  possible  to  group  the  various  combinations  of  symptoms 
exhibited  in  different  cases  into  three  fairly  distinct  classes.  These 
forms  of  general  miliary  tuberculosis  are  designated  the  pneumonic 
type,  because  of  the  predominance  of  symptoms  referable  to  the  lungs 
ami  ihc  iriosfuition  of  definite  physical  signs;  the  typhoidal,  from  the 
( 1(1-1  ■  -mil  il  It  ion  of  typhoid  fever;  and  the  Jneningeal,  by  reason  of  clinical 
data  iiniiituig  conclusivel.v  toward  a  cerebral  involvement.  It  is  not 
always  possible  to  differentiate  closely  between  these  three  varieties 
of  miliary  tuberculosis.  No  matter  how  clearly  defined  the  early 
manifestations  and  how  threctly  suggestive  of  either  the  typhoidal  or 
the  pneumonic  type,  a  meningeal  tubercidosis  not  infrequently  super- 
venes as  a  terminal  condition.  Many  cases,  however,  are  distinctly 
typhoidal.  pulmonary,  or  meningeal  from  the  beginning  to  the  very 
end.  Even  among  cases  closely  conforming  to  any  single  variety  of 
miliary  tuberculosis  a  very  considerable  latitude  is  observed  in  the 
combination  of  clinical  symptoms.  A  purel.y  typical  case  of,  respec- 
tively, the  pulmonary,  typhoidal,  or  meningeal  form  is  easily  the  subject 
of  text-book  de.scription,  l)ut  as  a  matter  of  clinical  observation  there 
are  often  noticed  in  the  same  general  class  conspicuous  tlifferences  in 
the  grouping  of  symptoms.  Cases  conforming  to  any  of  the  distinct 
varieties  may  be  of  abrupt  onset  or  they  may  begin  with  less  defined 
symptoms.  There  is  also  noted  a  striking  variation  in  the  cour.se  and 
duration.  Cases  of  the  typhoidal  t3-pe  may  be  attended  with  consider- 
able  temperature  elevation  or   may   be  purely  afebrile  throughout. 


GENERAL    CONSIDERATIONS  327 

The  various  combinations  of  symptoms,  particularly  in  the  typhoidal 
and  the  meningeal  forms,  are  exceedingly  numerous,  and  yet  the 
clinical  picture  in  each  instance  may  be  sufficiently  characteristic  to 
permit  its  classification.  In  a  series  of  cuscs  of  inoningeal  tuberculosis 
certain  manifestations  or  groups  of  syiii|iioiiis  may  l.)e  present  in  some 
and  entirely  absent  in  others.  Tliis  is  illust  rated  liy  the  inconstancy 
of  rigidity  of  the  neck,  retraction  of  the  head,  vomiting,  constipation, 
inequality  of  the  pupils,  irre.mihu-  pulse,  retraction  of  abdomen,  changes 
in  the  reflexes,  spasm,  and  jjai-alysis. 

In  spite  of  the  wide  range  in  the  clinical  data  and  the  incompetency 
of  single  symptoms  as  immutable  features  of  diagnosis,  accurate  inter- 
pretations as  to  the  significance  of  the  varied  manifestations  are  usually 
affortled.  In  meningeal  tuberculosis  it  has  been  found  that  age  exerts 
an  especial  influence  in  determining  the  nature  of  the  clinical  picture, 
certain  comljined  symptoms  unusual  in  childhood  being  more  or  less 
characteristic  of  infancy.  A  single  disease  capable  of  producing  so 
infinite  a  variety  of  subjective  and  objective  manifestations,  when  unac- 
companied by  recognizable  evidences  of  pulmonary  tuberculosis,  must 
of  necessity  present  added  difficulties  in  the  way  of  clinical  different  iution 
and  interpretation  of  symptoms,  when  developing  as  a  cniiijilii-ii/ion  of 
an  intrathoracic  infection  associated  with  more  or  less  systemic  disturli- 
ance.  The  early  symptoms  of  general  miliary  tuberculosis  are  especially 
obscure  when  this"  condition  complicates  a  preexisting  pulmonary  infec- 
tion. Thus  the  significance  of  fever  incident  to  a  beginning  miliary 
involvement  is  entirely  lost  in  a  distinctly  febrile  case  of  pulmonary 
phthisis. 

One  of  the  chief  obstacles  to  the  early  recognition  of  acute  miliary 
tuberculosis  relates  to  the  predominance  of  general  symptoms  over  local 
manifestations  until  late  in  the  disease.  The  systemic  disturbances  are 
occasioned  liy  the  toxic  absorption  which  takes  place  a  few  hours  after 
the  entrance  of  bacilli  and  soluble  poisons  into  the  blood,  while  the  local 
phenomena  are  due  solely  to  the  formation  of  tubercles,  which  are  of 
much  later  development.  Thus  it  happens  that  the  clinician  is  often 
unable  to  ascribe  a  definite  pathologic  significance  to  preliminary  symp- 
toms, and  is  compelled  to  approximate  his  early  conclusions  upon  the 
basis  of  combined  general  manifestations  and  a  review  of  all  possilie 
etiologic  factors.  The  varied  combinations  of  clinical  features  in  miliary 
tuberculosis  are  entirely  inexplicable,  save  upon  the  score  of  essential 
differences  attending  the  entrance  of  bacilli  and  toxins  into  the  blood- 
vessels. Widely  divergent  symptoms  in  different  individuals  are  depen- 
dent upon  the  site  of  the  original  focus  of  infection,  the  relative  number 
of  bacilli,  and  the  amount  of  soluble  poison  introduced  into  the  circu- 
lation. According  to  the  location  of  the  eruptive  source,  the  bacilli  may 
find  their  way  directly  to  the  left  ventricle  and  enter  the  larger  circulation 
for  distribution  throughout  the  entire  body,  or  proceed  to  the  terminals 
of  the  pulmonary  arteries  through  the  intervention  of  the  lungs.  In  this 
manner  there  is  exerted  to  no  small  degree  an  influence  upon  the  character 
of  the  ensuing  manifestations.  The  number  of  tubercle  bacilli,  together 
with  the  amount  of  soluble  poison  entering  the  circulation,  produce  a  deter- 
mining effect  upon  the  severity  of  the  general  symptoms  and  the  extent 
of  tuljcrcle  formation.  Their  ingress  into  the  blood-stream  is  subject 
to  enormous  variation  according  to  the  size  and  number  of  degenerating 
vascular  foci.     The  entrance  of  comparatively  few  bacilli  into  the  cir- 


328  COMPLICATIONS 

dilation  from  a  single  eruptive  focus  may  not  produce  a  widely  dis- 
seminated tubercle  deposit,  and  if  not  followed  by  successive  crops,  may 
cause  clinical  disturbances  of  but  temporary  duration,  sometimes  result- 
ing in  apparent  recovery.  It  unfortunately  happens  that  in  the  large 
majority  of  cases  opportunity  is  afforded  for  a  renewed  discharge  of 
tubercle  contents  into  the  circulation  from  the  same  focus,  and  that 
egress  of  microorganisms  from  similar  foci  often  takes  place  in  other  parts 
of  the  vascular  system.  This  permits  a  ready  explanation  of  the  occa- 
sional exacerbation  of  temperature  and  other  clinical  disturbances  follow- 
ing such  a  quiescence  of  symptoms  as  to  suggest  a  possible  recovery. 

Differences  in  the  virulence  of  the  bacilli  and  toxins  introduced  into 
the  circulation  from  an  eroded  tuberculous  area  are  not  without  their 
proportionate  influence  in  characterizing  the  severity  of  both  the  general 
and  the  local  symptoms.  Cornet  has  called  attention  to  the  fact  that 
bacilli  discharged  from  a  recent  focus  of  infection  are  much  more  active 
in  producing  general  tubercle  formation  than  the  attenuated,  broken- 
down  microorganisms  from  a  non-progressive  and  long-standing  tuber- 
culous process.  On  the  other  hand,  he  attributes  especial  virulence  to 
the  soluble  poisons  accompanying  the  latter  type  of  bacilli,  and  a  com- 
paratively benign  toxic  effect  to  the  former  variety.  Irrespective  of 
the  verity  of  this  assertion  it  would  appear  that  the  age  of  the 
patient,  the  previous  condition,  the  degree  of  emaciation,  and  the  capac- 
ity for  absorption  must  play  an  important  part  in  the  severity  of  the 
toxic  manifestations.  Certain  it  is  that  the  hypothesis  as  to  an  increa.sed 
virulence  of  the  toxemia  produced  by  attenuated  bacilli  is  not  borne 
out  by  the  clinical  evidences  in  pulmonary  tuberculosis.  In  my  exper- 
ience the  lesser  amount  of  toxic  absorption  has  u.sually  been  observed 
when  the  bacilli  have  shown  a  tendency  toward  degeneration  andattenua- 
tion,  and  the  greater  toxemia  coincident  with  the  pre.sence  of  the 
so-called  virulent  microorganisms.  If  this  obtains  in  pulmonary  tuber- 
culosis in  which  the  absorption  of  soluble  poisons  into  the  circulation 
is  often  slow,  it  is  difficult  to  comprehend  why  the  same  relation  should 
not  hold  true  when  the  toxins  enter  the  blood-stream  directl}'  instead 
of  through  the  medium  of  the  lymphatics.  If  this  is  not  the  case,  gen- 
eral miliary  tuberculosis  developing  in  individuals  harboring  non-active 
or  quiescent  lesions  with  attenuated  bacilli  would  be  expected  to  exhibit 
a  more  severe  toxemia  than  in  consumptives  suffering  from  rapidly 
advancing  infection.  This  scarcely  is  in  accord  with  my  personal 
observations.  I  have  found  the  general  sj'mptoms  more  marked,  as  a 
rule,  when  the  miliary  condition  complicates  an  active  destructive 
change.  This  has  been  especially  true  in  children  in  whom  the  severity 
of  the  general  symptoms  is  characteristic,  the  facilities  for  absorption 
more  pronounced,  and  the  active  virulent  nature  of  the  infection  strik- 
ingly manifest. 

Regardless  of  any  fixed  relation  between  the  toxic  symptoms  and 
the  specific  characteristics  of  the  bacilli,  it  is  sufficient  for  pre.sent  pur- 
poses to  recognize  simply  that  marked  differences  exist  in  the  viru- 
lence both  of  the  bacilli  and  of  the  soluble  poisons  sufficient  to  stamp 
their  impress  upon  the  clinical  picture.  Tlii<  ji.illm^pnic  variation  in 
individual  cases  offers  perhaps  a  partial  cxphiiKiUnii  1,1'  the  remarkable 
differences  in  the  clinical  course  of  miliary  iul;n.  u1(j.-is  which  otherwise 
would  remain  com])letely  inexplicable. 


THE    PXEUMOXIC   TYPE  329 


CHAPTER  XLVI 
THE  PNEUMONIC  TYPE 

General  miliary  tuberculosis  with  predominating  symptoms  refer- 
able to  the  lungs  may  occur  in  the  midst  of  apparent  health,  or  it 
may  exist  as  one  of  the  complications  of  chronic  pulmonary  tuber- 
culosis. A  preexisting  focus  of  tuberculous  infection  is  absolutely 
essential  for  its  development.  This  form  of  miliary  tuberculosis  may 
begin  somewhat  abruptly,  or  the  onset  may  simulate  the  development 
of  catarrhal  bronchitis.  The  rapid  fulminating  type  with  brusque 
initial  symptoms  has  been  described  in  connection  with  the  acute  onset 
of  pulmonary  tuberculosis.  The  first  manifestations  of  the  pulmonarj' 
variety  of  miliary  tuberculosis  may  he  moderate  rigors  and  other  evi- 
dences of  systemic  disturbance,  as  fever,  incUsposition,  and  headache. 
Attention  is  early  directed  to  the  lungs  by  cough,  dyspnea,  and  cyan- 
osis. As  a  rule,  the  cough  is  frequent,  distressing,  and  unattended  at 
first  by  expectoration.  The  sputum,  if  present,  is  of  but  slight  amount, 
and  noticeably  thin  or  frothy  in  character.  Patients  sometimes  succuml) 
to  the  malady  before  the  appearance  of  expectoration.  Rarely  is  it 
purulent,  and  then  only  in  the  later  stages  of  the  disease,  when  the 
clinical  manifestations  clearly  show  the  desperate  nature  of  tlie  con- 
dition. Streaks  of  blood  occasionally  discolor  the  expectoration,  or 
it  may  assume  a  distinctly  rusty  liue.  Although  tubercle  bacilli  are 
rarely  found  in  the  sputum,  the  clinical  evidences  of  miliary  infection 
are  fairly  conclusive.  Two  of  the  most  important  subjective  features 
are  the  dyspnea  and  the  ci/anosis,  both  of  which  greatly  exceed  the 
significance  ordinarily  attached  to  the  physical  findings.  Sometimes 
these  symptoms  are  found  to  precede  the  cough,  the  dyspnea  in  par- 
ticular often  being  the  first  to  attract  the  attention  of  the  patient.  In 
most  cases  this  increases  rapidly  in  association  with  an  aggravation  of 
cough  and  progressive  loss  of  strength.  Some  cases  are  devoid  of  special 
cyanosis,  but  this  is  quite  unusual.  The  patient  is  often  extremely 
nervous  and  apprehensive,  but  rarely  appreciative  of  the  extreme  grav- 
ity of  the  condition. 

Fever  is  present  only  to  a  moderate  extent,  the  temperature  sel- 
dom being  elevated  above  102°  or  103°  F.  Its  course  is  extremely 
irregular,  marked  differences  of  temperature  being  noted  on  succeeding 
days.  It  is  sometimes  higher  in  the  afternoon  than  in  the  morning, 
while  in  other  ca.ses  the  inverse  type  of  fever  is  displaj'ed.  This  lack 
of  periodicity  in  the  temperature  elevation  is  often  an  interesting 
feature  in  connection  with  the  disease.  Iliuh  lV\ci-  usually  yields  to 
cold  baths,  but  often  rises  again  after  a  l)rici'  iiiicr\al.  The  daily  fall 
of  temperature  is  attended,  as  a  rule,  by  iiH)(lci;iicly  ]irofusi 
Chilly  sensations  are  frequent  in  the  course  of  the  day.  citlic 
or  accompanying  the  development  of  fever.  The  pul^c  is 
rapid,  soft,  and  easily  compressible,  the  blood-pressuic  aim 
being  found  materially  reduced.  There  is  ra])i(l  loss  of 
strength,  with  diminution  of  appetite  and  impairnunt  of  diiii 

Upon   examination   the   physical    signs   are    ap])areiitly 
comparison  with  the  subjective  evidences  of  systemic  infection  and 
respiratory  incapacity.     There  is  rarely  dulness  upon  percussion,  save 


'  sweat: 

ing. 

pn.c.M 

ling 
bly 

ist   alw" 

avs 

flesh    ; 

and 

•stion. 

trivial 

in 

330  COMPLICATIONS 

in  the  exceptional  development  of  moderately  large  areas  of  broncho- 
pneumonia in  children.  In  some  cases  a  general  tympanitic  resonance 
is  elicited.  Upon  auscultation,  as  a  rule,  no  modifieations  of  the  nor- 
mal respiratory  sounds  are  heard,  though  occasionally  a  roughening  of 
the  vesicular  quality  is  detected.  The  adventitious  sounds,  however, 
are  quite  characteristic,  the  one  distinguishing  /eature  of  the  physical 
examination  consisting  of  innumerable  very  fine  and  moist  rules.  These 
are  disseminated  throughout  all  portions  of  each  lung,  the  signs  being 
those  of  a  diffused  catarrhal  bronchiolitis.  The  rales  may  be  entirely 
absent  upon  ordinary  respiration,  but  are  detected  reatlily  during 
inspiration  following  a  short  cough.  Jiirgenson  has  called  attention  to 
occasional  friction-rubs  of  a  peculiar  soft  character,  due  to  tuberculosis 
of  the  pleura,  and  heard  both  upon  inspiration  and  expiration. 

Cases  of  the  pulmonary  type,  beginning  with  less  acute  onset,  may 
simulate  for  a  time  the  typhoidal  form  of  general  miliar}^  tuberculosis. 
Although  the  cough  may  chance  to  be  a  subordinate  feature,  the  increas- 
ing dyspnea  and  deepening  cyanosis  are  sufficient  to  suggest  a  probable 
pulmonary  involvement,  which  is  suljject  to  confirmation  by  the 
physical  signs.  The  course  of  the  di.sease  in  most  cases  is  short,  the 
patient  usuallj-  exhibiting  a  rapid  ami  uninterrupted  decline  from 
the  beginning  to  the  end.  The  duration  is  seldom  longer  than  a  few 
weeks,  althouiih  a  marked  abatement  of  the  previous  rapid  progress 
is  occasionally  exliilutcd.  I  have  observed  a  number  of  cases  of 
undoubted  miliary  tul)erculosis  of  the  pneumonic  variety  presenting 
features  of  decided  chronicity.  In  some  cases  the  di.sease  has  assumed 
a  chronic  aspect  partaking  of  the  essential  characteristics  of  ordinary 
pulmonary  tuberculosis.  General  miliary  tuberculosis,  irrespective  of 
its  particular  type,  has  formerly  l^een  regarded  as  invariably  fatal. 
Actual  recoveries  from  the  pneumonic  variety,  as  well  as  others  to  be 
described,  are  occasionally  reported.  I  have  had  occasion  to  note  its 
stay  of  execution  in  several  instances,  and  the  adoption  of  a  protracted 
course,  but  rarely  an  apparent  complete  arrest. 

I  have  under  my  care  at  the  present  time  a  young  man  exhibiting 
characteristic  evidences  of  the  ])iilinimar\"  form  of  general  miliary 
tuberculosis.  His  attending  phy~i'  i:iu  in  a  distant  portion  of  the 
country,   in  referring  the  patient    tor   climatic   change,   wrote:    "The 

bearer,  Mr. has  miliary  tuberculosis,  having  had  this  condition 

for  about  two  and  one-half  months."  At  the  time  he  came  under 
my  observation  the  history,  subjective  symptoms,  and  physical  signs 
were  such  as  to  justify  an  assumption  of  pneumonic  miliary  invasion. 
Exceedingly  fine  semidry  rales  were  heard  throughout  both  lungs. 
The  dyspnea  was  entirely  out  of  proportion  to  the  physical  evidences. 
Extreme  pallor  and  physical  weakness  were  apparent.  The  cough 
was  slight  and  the  expectoration  scanty;  an  occasional  bacillus  was 
detected  only  after  long  searching.  Marked  fluctuations  characterized 
a  moderate  daily  temperature  elevation.  The  pulse  was  very  weak, 
irregular,  rapid,  and  easily  compressible.  63-  virtue  of  continuous  rest 
in  the  recumbent  position  the  patient  has  displayed  a  material  gain  in 
weight,  with  corresponding  reduction  of  temperature.  The  dyspnea  is 
somewhat  less  than  at  the  time  of  arrival.  While  the  ultimate  prognosis 
is  at  best  uncertain,  there  has  taken  place  a  pronounced  recession  in  the 
severity  of  the  symptoms,  suggesting  at  least  the  possibility  of  a  further 
retardation  in  the  progress  of  the  disease. 


THE    TYPHOID    TYPE  331 

In  striking  contrast  to  the  above,  the  following  case  is  of  especial 
interest,  illustrating,  as  it  does,  the  more  frequent  clinical  course  after 
the  advent  of  a  miliary  invasion  of  the  pneumonic  type. 

In  1904  a  young  man  of  about  thirty  years  of  age,  a  former  patient 
of  Dr.  V.  Y.  Bowditch,  was  seen  in  consultation  with  Dr.  C.  E.  Edson,  one 
month  after  arrival  in  Colorado.  At  the  time  climatic  change  was 
advised  the  disease  had  been  of  comparatively  short  duration  and  the 
general  condition  was  excellent.  There  had  been  but  little  cough 
and  expectoration,  nutrition  was  but  little  impaired,  and  the  tempera- 
ture elevation  was  very  slight.  The  physical  signs  denoted  but  an 
incipient  infiltrative  process  at  the  right  apex.  Upon  full  inspiration 
following  a  cough  fine  clicks  were  occasionally  heard  from  the  apex 
to  the  second  rib.  The  condition  was,  of  course,  such  as  to  justify  an 
optimistic  prognosis.  After  three  weeks'  i-esidence  in  Colorado  there 
developed  abruptly  a  moderate  dyspnea,  which  for  a  time  was  incapable 
of  rational  explanation.  This  increased  with  each  succeeding  day 
until,  after  an  interval  of  a  week,  the  shortness  of  breath  became  very 
pronounced.  The  dyspnea  was  accompanied  by  a  moderate  dusky 
discoloration  of  the  face  and  finger-nails.  Much  physical  debility  was 
exhibited  as  the  air-hunger  became  more  extreme.  There  was  but 
slight  cough,  with  thin,  frothy  expectoration.  The  temperature  eleva- 
tion at  no  time  had  exceeded  100°  F.  Physical  examination  was 
negative  until  the  expiration  of  one  week  after  the  onset  of  acute 
manifestations.  At  this  time  numerous  exceedingly  fine,  semidry 
clicks  were  heard  throughout  all  portions  of  each  lung.  The  rales  were 
very  fine,  without  partaking  of  a  bubbling  character,  and  at  first  were 
almost  imperceptible.  The  expectoration  gradually  assumed  a  pinkish 
hue,  ami  later  became  more  definitely  blood-tinged.  A  cUagnosis  of 
the  pulmonary  form  of  miliary  tuberculosis  was  rendered,  together 
with  an  unfavoral)le  prognosis.  The  patient  survived  less  than  three 
weeks,  the  suffering  becoming  daily  more  intense  by  virtue  of  the 
inordinate  hunger  for  air. 

This  case  is  particularh^  instructive  as  illustrating  the  development 
of  the  pneumonic  invasion  in  the  midst  of  an  apparently  benign  infec- 
tion, the  remarkably  rapid  decline  to  a  fatal  issue,  and  the  striking 
disproportion  between  the  dyspnea  and  the  physical  signs. 


CHAPTER   XLVII 

THE  TYPHOID  TYPE 

The  onset  of  this  form  of  miliary  tuberculosis  is  characterized 
by  the  development  of  vague  and  indefinite  symptoms.  In  some 
instances  the  early  manifestations  may  be  decidedlj-  more  acute 
than  in  others,  and  include  moderate  rigors,  temperature  elevation, 
and  headache.  Usually,  however,  there  is  a  preliminary  history  of 
lassitude,  physical  weakness,  and  indisposition  of  from  several  days' 
to  two  weeks'  duration.  Frequently  complaint  is  made  of  pain  in  the 
head,  anorexia,  and  constipation,  the  frontal  headache  being  a  con- 


332  COMPLICATIOXS 

spicuous  feature  in  very  many  cases.  Often  the  repugnance  to  the  sight, 
smell,  or  even  the  thought  of  food  is  extreme.  The  patient  at  first  is 
restless  or  excitable,  but  there  is  manifested  a  disinclination  to  physical 
activity.  The  sleep  is  broken  by  disturbing  and  usually  unpleasant 
dreams.  The  tongue  may  be  coated  heavily,  but  the  breath  rarely 
assumes  the  offensive  oclor  characteristic  of  typhoid  fever.  There 
is  moderate  elevation  of  temperature,  with  frequent  morning  remissions 
and  evening  exacerbations,  as  in  typhoid,  but  the  fever,  as  a  rule,  does 
not  attain  so  high  a  point  as  in  the  latter  chsease.  A  factor  of  vital 
importance  is  its  variable  atypical  course,  even  an  afebrile  condition 
being  no  contraindication  of  the  possible  existence  of  miliary  tuberculo- 
sis. While  in  exceptional  cases  the  fever  is  ab.sent  altogether,  it  some- 
times is  higher  in  the  morning  than  at  night,  thus  conforming  to  the 
inverse  type.  In  the  same  individual  upon  different  days  the  exacerba- 
tions of  temperature  elevation  may  take  place  either  in  the  morning  or 
at  night.  The  distinguishing  characteristic  of  the  fever  is  its  extreme 
irregularity.  The  atypical  curve  is  strongly  suggesti-\-e  of  miliary  tuber- 
culosis in  contrachstinction  to  typhoid  fever,  but  a  temperatm-e  con- 
forming closely  to  that  of  typhoid  affords  no  insuperable  argument 
against  the  tuberculous  character  of  the  affection.  The  daily  subsidence 
of  fever  is  frequently  attended  by  moderate  perspiration,  although  this 
is  observed  less  often  than  in  typhoid.  Also  the  elevated  temperature 
is  decidedly  more  responsive  to  baths  or  cold  sponging.  In  nearly  all 
cases  the  pulse  is  markecUy  accelerated  from  the  very  beginning,  rarely 
declining  to  under  100,  and  usually  ranging  from  1 10  to  130.  It  is  almo.st 
invariably  soft,  easily  compressible,  and  occasionally  dicrotic.  As  the 
diseiise  advances,  the  respirations  are  likely  to  be  more  rapid  than 
in  typhoid  fever,  although  often  incapable  of  satisfactory  explanation 
from  the  results  of  physical  examination.  In  later  stages  the  character- 
istic Cheyne-Stokes  type  of  breathing  not  uncommonly  makes  its  appear- 
ance. Cough  may  be  present  in  typhoid  fever  as  an  initial  symptom, 
and  develop  later  in  the  course  of  the  disease  on  account  of  a  concurrent 
bronchopneumonia  or  hypostatic  congestion.  This  may  be  confused 
with  the  frequent  distressing  cough  which  sometimes  constitutes  a 
clinical  feature  of  miliary  tuberculosis.  This  symptom,  together  with 
dyspnea  and  cyanosis,  is  particularly  characteristic  of  those  cases  in 
which  the  typhoid  type  of  the  chsease  gradually  merges  into  the  pulmo- 
nary. Nosebleed  is  sometimes  observed  as  in  typhoid,  though  less 
frequently.  Neither  its  presence  nor  its  absence  should  be  regarded 
as  especially  suggestive  of  the  nature  of  the  disturbance.  The  headache 
is  subject  to  considerable  variation  in  each  disease.  It  is  u.sually  more 
severe  in  miliary  tuberculosis,  and  is  likely  to  increase  in  severity  rather 
than  the  reverse,  as  in  typhoid.  Early  in  the  cour.se  there  may  exist  the 
same  restlessness  and  nervous  excitabilit_v  and  subsequently  mental 
hebetude,  drowsiness,  stupor,  and  finally  delirium  or  coma.  In  mili- 
ary tiilHTciil(i-;is  there  is  often  exhibited  at  different  times  a  striking 
variation  .ii  iIk  mental  condition  in  the  same  individual.  The  patient, 
upon  111  iiii;  aiiii-cd  from  a  moderate  .stupor  or  even  a  heavy  sleep,  may 
regain  full  pos-ession  of  the  faculties  for  the  time  being,  only  to  lapse  into 
a  drowsy  indifference  when  the  attention  is  withdrawn.  A  mild  delirium 
in  like  manner  may  give  way  to  a  rational  coherence  of  tliovitrht  and 
utterance  for  a  brief  period.  These  abrupt  changes  in  the  mental  status 
no  doubt  are  occasioned  in  pai't  1)V  differences  in  the  degree  of  toxic 


THE    TYPHOID    TYPE  333 

absorption,  and  are  somewhat  suggestive  of  tuberculosis.  Tlie  mutter- 
ing delirium  and  singultus  coincident  with  profound  stupor,  though 
present  at  times,  are  probably  observed  less  often  than  in  typhoid. 
Herpes  is  rarely  present  in  typhoid,  but  is  noted  frequently  in  the 
early  course  of  acute  miliary  tuberculosis.  Rapid  loss  of  flesh  and 
strength  are  characteristic  of  the  two  conditions.  Generally  speaking, 
the  flushed  face  of  typhoid  is  contrasted  with  the  pronounced  pallor 
which  usually  accompanies  miliary  tuberculosis,  especially  during  the 
afebrile  period.  Diarrhea  and  meteorism  may  be  present  in  each  disease, 
and  the  abdomen  may  be  either  retracted  or  distended.  Rose-spots, 
though  regarded  as  a  distinguishing  feature  of  typhoid,  are  sometimes 
present  in  miliary  tuberculosis.  The  spleen  is  enlarged  to  a  greater 
extent  in  typhoid,  in  which  condition  it  is  almost  always  palpable. 
Leukocytosis  may  be  detected  in  miliary  tuberculosis,  rarely  in  typhoid. 
The  diazo-reaction  may  be  recognized  in  both  conditions,  and  has, 
therefore,  but  slight  diagnostic  value.  Albuminuria,  while  sometimes 
observed  in  typhoid,  is  more  often  present  in  miliary  tuberculosis.  In 
this  condition  tubercle  bacilli  are  reported  to  have  been  demonstrated 
in  the  blood,  but  while  their  presence  is  undoubtedly  of  positive  value, 
their  absence  possesses  no  negative  significance.  In  like  manner  recog- 
nition of  choroidal  tubercle  is  conclusive  evidence  of  miliary  tuberculosis, 
but  its  absence  on  repeated  examinations  does  not  negative  the  existence 
of  the  disease.  The  Widal  test  is  of  the  utmost  value,  and  may  be 
regarded  as  definitely  ilecisive  of  typhoid.  The  presence  of  tubercle 
bacilli  in  the  cerebi-ospinal  fluid,  as  demonstrated  by  lumbar  puncture, 
also  offers  incontrovertible  evidence  of  a  miliary  invasion. 

It  is  beyond  dispute  that  some  cases  do  not  admit  of  positive 
diagnosis  until  the  autopsy  findings  are  disclosed.  Provisional  infor- 
mation is  furnished  by  the  prevalence  of  a  typhoid  epidemic  in  the 
immediate  neighboi-hood,  the  existence  of  tuberculosis  in  the  same 
household,  or  the  history  of  important  predisposing  causes.  Thus 
coexisting  or  antedating  pulmonary  tuberculosis,  enlarged  lymph- 
atic glands,  tuberculosis  of  bones  and  joints,  icUopathic  pleurisies, 
or  in  children  a  recent  whooping-cough  or  measles,  would  suggest 
a  general  miliary  tuberculosis  on  account  of  the  recognized  facility 
for  general  infection.  Even  in  iloubtful  cases  an  accompanying  tuljer- 
culous  process  in  other  parts  of  the  body  does  not  offer  conclusive 
evidence  of  a  general  bacillary  invasion.  Pulmonary  invalids  are  quite 
as  likely  to  contract  typhoid  fever  as  non-consumptives,  but  the  presence 
of  bacilli  in  the  sputum  at  least  strengthens  to  a  considerable  extent  the 
theory  of  a  general  infection.  It  must  not  be  understood,  however, 
that  a  negative  history  of  tuberculosis  in  association  with  other  s_ymp- 
toms  precludes  the  possibility  of  miliary  tuberculo.sis. 

Attention  to  the  above  features  of  differential  diagnosis  suffices  for 
the  accurate  determination  of  the  conc'ition  in  the  great  majority  of 
cases,  although  in  some  instances  a  definite  conclusion  is  quite  impossil)le 
during  life.  As  a  rule,  failure  to  establish  a  correct  diagnosis  in  cases  of 
this  type  of  miliary  tuberculosis  is  not  occasioned  so  much  by  reason  of 
any  lack  of  credible  data  for  this  purpose,  as  through  neglect  on  the  part 
of  the  physician  to  utilize  properly  the  means  which  are  available.  A 
single  instance  from  my  recent  experience  is  cited  for  the  sake  of  illus- 
tration. 

1  .saw,  in  consultation  with  a  prominent  and  respected  member  of 


334  LOMPLICATIOXS 

the  profession,  a  man  of  forty-fi\e  years,  who  was  stated  to  have  been 
suffering  from  typhoid  fever  for  three  months.  In  the  absence  of  a  pre- 
vailing epidemic  the  physician  in  charge  had  made  the  diagnosis  during 
the  first  week  of  his  illne.ss  upon  the  basis  of  headache,  fever,  general 
intlisposition,  and  repugnance  for  food.  Throughout  the  entire  period 
of  illness  the  physician  extended  assurances  that  defervescence  must 
shortly  be  established.  The  medical  attendant  asserted  that  he  had 
been  privileged  to  observe  nearl}-  1000  cases  of  typhoid  fever,  anil  that 
the  accuracy  of  the  diagnosis  was  beyond  question.  Upon  preliminary 
inquiry  I  elicited  the  information  that  there  had  been  no  nosebleed,  no 
enlarged  spleen,  no  rose-s]5ots,  and  that  the  Widal  test  had  not  been 
emploj-ed.  The  examination  of  the  fever-chart  disclosed  an  irregular, 
jagged  line  of  temperature  elevation.  During  most  of  the  time  there 
were  morning  exacerbations  and  evening  remissions,  followed  by  exces- 
sive perspiration.  The  tongue  had  not  Ijeen  coated  at  any  period  of 
the  disease.  At  no  time  was  the  intellect  clouded  to  the  .slightest 
degree.  It  was  apparent,  even  before  seeing  the  patient,  that  the 
diagnosis  of  tj-phoid  fever  was  almost  untenable.  It  de\eloped  that  the 
invalid  several  years  before,  had  been  pronounced  an  arrested  case  of 
pulmonary  tuberculosis.  Upon  examination  the  evidences  of  general 
miliary  tuberculosis  were  of  a  very  suggestive  character,  and  a  definite 
suspicion  was  entertained  as  to  a  threatening  meningeal  invasion. 
Two  days  later  the  patient  developed  a  sudden  apoplectiform  attack, 
resulting  in  profound  coma  from  which  he  ne\'er  emerged. 

This  case  is  rather  a  striking  commentary,  not  upon  the  difRculties 
in  the  way  of  accurate  diagnosis,  but  upon  the  ease  with  which  vital 
clinical  data  may  be  overlooked. 

The  course  of  this  form  of  miliary  tuberculosis  is  exceecUngly  variable, 
the  duration  extending  from  ten  days  to  several  months.  In  the  more 
acute  cases  the  progress  may  be  sufficiently  rapid  to  produce  death 
within  one  or  two  weeks.  Such  fulminating  cases  are  not  uncommon. 
Others,  after  a  variable  period,  exhibit  the  .symptoms  and  signs  of  pulmo- 
nary involvement,  i.  e.,  the  increasing  rapicUty  of  the  respirations,  the 
cough  and  cyanosis,  the  Jiirgenson  friction-rub,  and  the  fine  rales  of 
diffuse  bronchiolitis.  Death  may  be  hastenetl  by  the  pulmonary  inva- 
sion or  by  the  onset  of  meningeal  complications.  Recover}'  from  miliary 
tuberculosis  has  always  been  regarded  as  extremelj'  rare,  if  not  alto- 
gether impossible,  but  authentic  cases  have  occasionally  been  reported. 
From  my  own  experience  I  can  recall  several  exceptional  instances  of 
recovery  from  supposed  miliary  tuberculosis  of  the  typhoid  type.  I 
have  in  mind  a  patient  who,  eleven  months  ago,  exhibited  in  another 
State  apparent  evidences  of  miliary  invasion,  although  the  condition 
was  at  first  regarded  by  attending  physicians  as  typhoid  fever,  -\fter 
the  lapse  of  two  months  the  extreme  prostration  was  followed  by  the 
characteristic  phj-sical  and  bacteriologic  manifestations  of  pulmonary 
involvement.  The  .severity  of  the  general  symptoms  finally  showed 
signs  of  abatement  and  the  patient  exhibited  suflficient  improve- 
ment to  justify  his  removal  to  Colorado.  Upon  arrival  there  were 
physical  evidences  of  a  disseminated  tubercle  deposit  involving  a  large 
portion  of  both  lungs,  very  fine  moist  i-ales  being  recognized  in  the 
absence  of  appreciable  consolidation.  The  pul.se  and  respir-ition  were 
both  rapid.  Complete  rest  in  the  open  air  during  a  period  of  six  months 
has  been  attended  by  a  gain  of  fifteen  pounds  in  excess  of  the  normal 


THE    MEXIXGEAL    FORM  335 

weight,  and  by  a  gradual  reduction  in  the  rate  of  the  pulse  and  respi- 
ration. Complete  absence  of  subjective  symptoms  and  a  negative 
physical  examination  constitute  in  this  case  the  final  result  of  an  initial 
condition,  which  was  presumably  miliary  in  character,  though  not  sub- 
ject to  absolute  confirmation.  Not  infrequently  cases  of  pulmonary 
tuberculosis  have  been  observed  whose  origin  was  referred  by  attending 
physicians  to  a  miliary  infection  of  the  typhoid  type.  I  have  not  been 
convinced  that  it  has  been  inrariabli/  more  difficult  to  secure  improve- 
ment in  cases  presenting  such  history  than  in  those  of  chronic  ulcerative 
phthisis.  This  anomalous  oxixM'ience  is  to  be  explained  largely  by  the 
fact  that  cases  of  mili:iiv  i  uhciculosis  conforming  to  the  typhoid  variety, 
as  a  rule,  are  not  penniltcd  ti.  seek  change  of  climate  until  the  begin- 
ning of  favorable  manil'estatiuns.  It ,  of  course,  cannot  be  contended  that 
in  general,  chronic  consumption  originating  from  general  miliary  tuber- 
culosis is  as  hopeful  as  ortlinary  phthisis. 


CHAPTER   XLVIII 

THE  MENINGEAL  FORM 

Pathogenesis. — The  meningeal  variety  of  miliary  tuberculosis  con- 
sists essentially  of  an  inflammation  of  the  pia  mater  resulting  from 
bacillary  infection.  The  condition  was  known  as  acute  hydrocephalus, 
dropsy  of  the  brain,  granular  meningitis,  or  basilar  meningitis,  long 
before  its  precise  origin  was  recognized.  It  may  be  assumed  in  all 
cases  to  be  secondary  to  a  preexisting  tubercle  deposit  in  other  parts  of 
the  body.  Although  it  is  sometimes  impossible  to  discover  antecedent 
tuberculous  processes  at  autopsy,  such  failure  does  not  establish  the 
existence  of  this  conchtion  as  a  primary  infection.  It  has  been  suggested 
that  the  original  bacillary  in\asion  may  take  place  through  the  nostrils 
and  the  cribriform  plate  of  the  ethmoid.  While  it  is  unnecessary  to 
attempt  to  controvert  this  possibility  in  very  exceptional  instances,  it 
may  be  accepted  as  true  that,  in  the  vast  majority  of  cases,  the  meningeal 
infection  is  secondary  to  a  primary,  though  perhaps  undisco^■el■abIe, 
focus  elsewhere.  It  is  often  comparatively  easy  to  recognize  tuberculous 
processes  of  undoubted  priority,  in  the  lym]ih-giands,  liones,  joints, 
lungs,  larynx,  kidmns,  l.hid.ln'  i;cni1al  or-aiis,  inlcsliiirs,  and  middle 
ear.  Meningeal  tubciculci^i-  may  "(■.•ur  al  aliii.isl  any  lime  of  life, 
though  rarely  during  tlie  iirst  year,  and  iulVc<)ucnlly  in  old  age.  As  a 
rule,  it  is  more  difficult  to  ascertain  upon  postmortem  examination  the 
precise  anatomic  origin  of  the  condition  in  young  people  than  in  later 
years.  In  infants  or  little  children  the  condition  sometimes  appears 
to  develop  de  novo,  the  autop.sy  findings  being  entirely  negative.  Its 
derivation  in  early  life  may  be  ascril)ed  in  many  cases  to  unsuspected 
tuberculous  infection  of  the  mediastinal  or  mesenteric  glands.  Among 
adults  it  occurs  most  frequently  in  connection  with  readily  disco\'erat3le 
pulmonary  tuberculosis.  Although  this  disease  furnishes  a  primary 
source  of  infection  for  many  cases  of  meningeal  tuberculosis,  comment 
has  been  made  upon  the  fact  that  the  latter  complication  is  not  of  more 


336  COMPLKATIOXS 

frequent  occurrence.  The  wonder  is  that,  with  the  innumerable  oppor- 
tunities for  blood-vessel  tuberculosis  in  pulmonary  phthisis,  miliary 
invasion  does  not  take  place  far  more  often  than  is  actually  the  case. 
An  interesting  and  somewhat  singular  clinical  phenomenon  is  the  lack 
of  relation  between  the  extent  or  degree  of  activity  of  the  pidmonary 
process  and  the  probable  occurrence  of  meningeal  infection.  Meningeal 
tuberculosis  is  quite  as  likely  to  result  in  connection  with  quiescent  cases 
of  pulmonary  tuberculosis  as  with  those  exhibiting  an  active  infection 
and  extensive  destructive  change. 

I  have  frequently  observed  the  development  of  this  complication 
among  pulmonary  invalids  who  presented  every  indication  sugges- 
tive of  a  favorable  issue.  I  ha\e  been  compelled  to  witness  its 
occurrence  even  among  patients  who  had  been  fortunate  enough  to 
secure  an  apparent  arrest  of  the  pulmonary  infection.  A  few  cases  of 
miliary  infection  are  recalled  in  individiuxls  who  for  years  had  exhibited 
upon  examination  every  appearance  of  perfect  health,  and  had  pursued 
lives  of  physical  activity  in  the  open  air.  Upon  the  basis  of  my  own 
observations  it  is  impossible  to  establish  any  relation  between  the 
activit}',  duration,  or  extent  of  the  pulmonary  process  and  the  suscepti- 
bility to  meningeal  complications.  Certain  other  conditions  seem  to 
possess  an  undoubted  bearing  upon  the  likelihootl  of  future  meningeal 
involvement.  Generally  speaking,  irritable  and  highly  excitable  indi- 
viduals have  been  found  to  develop  meningeal  tuberculosis  more  fre- 
quently than  those  of  phlegmatic  temperament.  The  cheerful  and 
sunny  in  disposition  are  less  prone  to  suffer  from  this  complication  than 
the  pessimistic  and  depressed.  I  have  observed  its  development  in 
numerous  cases  following  a  protracted  season  of  severe  nervous  strain 
or  emotional  chsturbance.  I  have  in  mind  a  man,  thirty-two  years  of 
age,  in  whom  the  arrest  of  the  pulmonary  infection  was  apparently 
complete,  who  experienced  unusual  mental  worry  and  depression  of 
spirits  from  a  rapid  culmination  of  unfortunate  events,  including  finan- 
cial reverses,  domestic  infelicities,  and  the  death  of  a  child.  Although 
nutrition  remained  unreduced  for  a  time  and  the  appearance  was  that 
of  remarkable  vigor,  tuberculous  meningitis  finally  supervened.  By  a 
strange  coincidence  his  wife,  exhibiting  a  slight  pulmonary  involvement 
and  a  nervous,  irritable  temperament,  also  succumbed  to  this  complica- 
tion after  a  period  of  profound  despondency.  Although  it  may  be  but 
one  of  the  anomalies  of  my  experience,  the  history  of  excessive  alco- 
holism has  frequently  been  associated  with  the  subsequent  development 
of  tuberculous  meningitis.  This  disease  has  been  found  to  be  more 
common  in  males  than  in  females.  Although  the  greater  portion  of  my 
patients  have  been  of  the  female  sex,  meningeal  invasion  has  not  been 
observed  among  them  nearly  so  often  as  among  the  males.  I  have 
seldom  witnessed  its  occurrence  in  pidmonary  invalids  over  fifty  years 
of  age,  presumably  on  account  of  the  lessened  opportunities  for  exten- 
sion of  tuberculous  processes  at  this  time  of  life. 

I  do  not  recollect  a  single  instance  of  its  development  among  the 
.Jews,  the  negroes,  or  the  Swedes.  It  has  appeared  less  often  among 
the  Irish  than  might  be  expected  from  their  mercurial  disposition  and 
excitable  temperament.  The  Scotch,  Germans,  and  Americans  among 
my  own  cases  have  suffered  from  this  complication  more  frequently 
than  other  nationalities. 

The  pathologic  changes  in  the  jna  mater  are  found  more  often  at 


THE    MENINGEAL    FORM  337 

the  base,  though  they  are  occasionally  present  at  the  sides  and  upon  the 
cortex.  The  tubercle  deposit  may  also  take  place  in  the  brain  substance, 
the  convolutions,  the  ventricles,  and  the  blood-vessels.  The  pia  may  be 
studded  by  the  eruption  of  few  or  numerous  miliary  tubercles,  varying  in 
size  from  a  pinpoint  to  a  small  seed.  Not  only  do  the  granulations  vary 
considerably  in  number  and  in  size,  but  also  with  reference  to  their 
location  and  attenchng  inflammatory  disturbance.  The  tubercles  often 
extend  along  the  course  of  the  blood-vessels,  and  are  present  particularly 
in  the  reflected  interior  spaces,  such  as  the  fissure  of  Sylvius,  around  the 
optic  chiasm,  and  the  anterior  and  po.sterior  perforated  spaces.  They 
are  sometimes  found  upon  the  lateral  surface  of  the  meninges,  but  rarelj' 
upon  the  conve.xity  of  the  hemispheres.  Considerable  difference  exists 
in  the  amount  and  character  of  the  inflammatory  exudate,  which  may 
be  of  a  serous,  fibrinous,  purulent,  or  sometimes  even  of  a  hemorrhagic 
nature.  In  some  cases  the  fluid  exudate  is  slight,  in  others,  compara- 
tively abundant.  The  upper  surfaces  of  the  brain  may  be  distinctly 
edematous,  or  they  may  be  normal  in  appearance.  Flattening  of  the 
convolutions  is  sometimes  observed,  particularly  at  the  bases.  The 
lateral  ventricles  are  often  distended  by  variable  amounts  of  fluid. 
Small  nodular  tubercles  may  occur  upon  the  arteries  of  the  anterior  and 
posterior  perforated  spaces.  Nodular  tuberculous  enlargements  are 
found  upon  the  smaller  arteries  (Osier).  Man}'  of  these  small  tubercles 
in  the  perivascular  sheaths  of  the  smaller  arteries  are  in  varying  stages 
of  caseation  (Collins).  The  changes  in  the  wall  of  the  blood-vessel  may 
consist  of  an  endarteritis  of  tuberculous  origin  with  intramural  pro- 
liferation as  a  result  of  the  invasion  by  the  bacilli  of  the  blood-stream 
(Hektoen).  Narrowing  and  obliteration  of  the  finer  vessels  often  take 
place.  Solitarj'  tubercle  of  the  pia  occasionally  results  from  the  confluence 
of  a  large  number  of  miliary  tubercles  confined  within  a  sharply  circum- 
scribed area.  In  such  cases  the  bacillary  invasion  takes  place  through 
a  single  small  meningeal  blood-vessel.  These  solitary  tubercles  some- 
times attain  astonishing  size,  without  producing  symptoms  suggestive 
of  their  presence.  This  may  happen  only  when  the  tubercle  chances 
not  to  encroach  upon  the  area  of  the  brain  having  jurisdiction  over 
special  functions.  It  is  often  separated  from  the  contiguous  brain  sub- 
stance by  an  area  of  granulation  tissue  (Collins). 

The  symptoms  of  tuberculous  meningitis  are  extremely  diverse  in 
character,  the  clinical  picture  being  decidedly  complex,  even  among 
patients  of  the  same  age.  It  is  impossible  to  describe  any  single  type 
to  which  all  cases  may  be  expected  to  conform.  It  is  interesting  to  note 
that  some  observers  have  described  the  symptoms  as  exceedingly  uniform, 
while  others  have  regarded  them  as  varied  and  indefinite.  Much  con- 
fusion results  from  the  fact  that  the  general  symptomatology  varies 
within  wide  limits,  accorchng  to  the  period  of  life  during  which  the  disease 
makes  its  appearance.  To  afford  greater  clearness  it  is  well  to  recognize 
essential  differences  in  the  mode  of  onset  and  course  of  tuberculous 
meningitis  among  adults,  young  children,  and  infants,  and  to  avoid  any 
attempt  toward  an  arbitrary  classification  of  .S3^mptoms  applicable  to 
varying  ages.  By  cHscriminating  sharply  between  the  clinical  mani- 
festations at  different  times  of  life,  the  so-called  atypical  cases  are  less 
frequent  in  actual  practice.  It  is  easy  to  comprehend  the  many  diffi- 
culties attending  any  attempted  exposition  of  a  single  group  of  symptoms 
to  be  submitted  as  a  single  type  of  the  disease,  and  to  appreciate  the 


338  CdJlPLKATIOXS 

innumerable  opportunities  for  error  resulting  from  such  effort.  It  is 
desired  to  distinguish  between  the  meningeal  tuberculosis  of  adults, 
developing  in  the  course  of  pulmonary  phthisis,  and  the  apparently 
primary  infection  of  children  and  of  infants. 

Symptoms  in  Adults. — Among  phthisical  patients  the  clinical 
manifestations  of  meningeal  invasion  are  somewhat  varied.  The  onset 
of  this  complication  during  the  course  of  pulmonary  lulx'iculdsis  may 
be  fairly  abrupt  in  some  cases,  while  in  others  the  begiuiiini;  :^yiii|j)()ms 
may  be  exceedingly  vague  and  indefinite.  Occasionally  the  uiitial 
manifestations  may  be  entirely  subjective  in  character,  and  develop 
with  sufficient  rapidity  to  surpass  in  importance  the  significance  of 
delayed  objective  phenomena.  At  other  times  the  local  signs  assume 
an  early  prominence  before  suspicion  of  a  meningeal  involvement  has 
been  awakened  by  subjective  symptoms.  The  clinical  evidences  of 
its  development  may  be  obscured  to  a  degree  l^y  the  fever  incident  to 
the  pulmonary  condition,  th>-  nuiscuhir  weakness  and  exhaustion,  the 
irritability,  digestive  chstuiliancc,  insomnia,  and  headache.  In  the 
absence  of  confusing  sym|it(iiii^,  li()\vi'\i"i-.  the  existence  of  a  pulmonary 
lesion,  rather  than  m.iskinu  ihc  dcx  rl(i|iuiciit  of  meningeal  tuberculosis, 
tends  to  emphasize  ilic  |H>"iliilit\  n\  it>  occun-cnce. 

The  more  frequent  nictlKid  of  diisci  (■<iiitni-ins  to  the  non-acute  type, 
exhibiting  a  preliminary  period  of  malaise  and  apathy,  followed  l\v  well- 
defined  subjective  and  objective  manifestations.  After  a  short  initial 
period  of  indisposition  there  develop  lack  of  appetite,  irregularity  of 
the  bowels,  disturbed  sleep,  moderate  elevation  of  temperature,  and, 
most  important  of  all,  a  continuous  severe  headache.  This  latter  symp- 
tom usually  increases  in  intensity  until  it  becomes  well-nigh  intolerable. 
The  pain,  as  a  rule,  is  confined  to  the  frontal  region,  but  is  sometimes 
located  at  the  back  of  the  head.  It  may  extend  down  the  neck,  which 
later  becomes  more  or  less  stiffened.  A  moderate  elevation  of  tempera- 
ture is  usually  found  m  (•(iiijun.ti<iii  with  ihe  hc;id;irho,  but  the  ab.sence 
of  fever  offers  no  coiii  i  a-siiuLK-^i  inn  as  lo  i  hr  iio.^mI  ilc  (■(U'xistence  of  men- 
ingeal infection.  I  \\:i\r  (il.<(T\-rd  a  coii^idcralilc  number  of  cases  pre- 
senting no  elevation  of  temperature  at  any  time  during  the  course  of 
this  complication.  Gastric  disturbances  are  not  infrequent  in  the  early 
stages,  expulsive  vomiting,  in  particular,  constituting  an  important 
symptom.  Headache,  fever,  and  vomiting,  if  of  joint  occurrence,  and 
independent  of  readily  assignable  cause,  are  strongly  suggestive  of  men- 
ingeal tuberculosis,  although,  as  will  appear  later,  this  condition  occa- 
sionally develops  without  exhibition  of  these  symptoms.  In  some  cases 
the  intellect  remains  unimpaired  for  many  days  despite  excruciating 
pain  in  the  head  and  inability  to  sleep  save  under  the  influence  of  an 
opiate.  Eventually,  however,  the  sen.sorium  becomes  clouded  and 
mild  delusions  take  place,  followed  by  increasing  stupor,  low  muttering 
delirium,  and  coma. 

Another  type  of  onset  among  adults  consists  of  an  early  blunting 
of  the  intelligence,  sometimes  without  fever,  headache,  or  vomiting. 
The  first  intimation  of  approaching  danger  is  conveyed  to  the  medical 
attendant  bj^  temporary  periods  of  rambling  discourse  and  wandering 
delirium,  with  increasing  tendency  toward  heavy  and  profound  .sleep. 
During  the  greater  portion  of  the  day  the  patient  is  in  evident  possession 
of  the  mental  faculties,  complains  of  nothing,  and  is  disinclined  to  talk 
save  at  the  time  of  brief  delusions,  which  are  rarely  unpleasant.     There 


THE    MENINGEAL    FORM  339 

is  seldom  any  apprehension  of  danger,  and  consequently  no  effort  to 
escape  from  imaginary  peril  or  to  inflict  injury  upon  others.  The  dura- 
tion of  these  periods  is  usually  short  in  the  beginning.  They  appear 
but  infrequently  during  the  first  few  days,  and  occur  during  the  night 
oftener  than  in  the  day.  These  mental  aberrations  may  take  place  in 
individuals  who  have  difficulty  in  sleeping,  as  well  as  in  those  evincing 
a  tendency  to  drowsiness.  After  a  few  days  the  flight  of  the  intellect 
becomes  more  frequent  and  longer  in  duration,  and  is  followed  in  many 
cases  by  pronounced  stupor.  At  such  a  time  the  patient  is  aroused  with 
difficulty  and  presents  at  first  an  appearance  of  sudden  bewilderment. 
Later  the  invalid  may  answer  questions  iiitelliiicntly  ;ind  seem  entirely 
rational,  though  inclined  to  silence  unless  ilosely  interi-ogated.  He 
soon  lapses  again  into  a  profound  slumber,  which  is  soineiiines  accoiii- 
panied  by  distressing  moaning,  more  as  if  in  ;i]>p;iriiii  xinmi^t  i-hk  e  to 
disturbing  visions  than  from  actual  pain.  Tlie  jterioil  ni  t  laiisit  khi  iidm 
these  conditions  to  the  state  ol'  comiilete  ({nua,  described  in  connection 
with  the  preceding  class  of  cases,  is  usii:ill\'  l)iief. 

Sometimes  the  uk  niiiucal  iiilectinn  ilex-elups  with  obstinate  vomiting 
or  hiccough,  which  precedes  for  days  all  oilier  niaiiilesialions  indicative 
of  the  condition.  I  recollect  one  instance  in  wliiili  the  nn^d  was  so 
distinctly  sudden  as  to  suggest  the  apopleetiloiin  metlioil  of  develop- 
ment. In  this  instance  tlie  patient  fell  to  the  floor  while  putting  on 
his  clothes,  and  mergeil  from  a  shoi  t  peiiod  of  consciou.sness  into  a  state 
of  delirium,  with  later  oeuhar  ami  motor  symptoms,  these  manifestations 
persisting  to  a  fatal  termination  in  ten  days. 

Among  some  consumptives  an  early  symptom  of  tuberculous  men- 
ingitis consists  merely  of  gi-eatly  increased  restlessness.  Such  patients 
are  especiall\-  apt  to  sidTer  from  insomnia.  The  delirium  which  finally 
develojis  in  these  cases  is  likely  to  be  acute  and  maniacal.  Among  these 
patients  loud  screaming,  both  hy  day  and  night,  is  not  infrequent.  The 
delusions  are  those  of  danger,  and  the  clinical  picture  is  not  markedly 
dissimilar  to  delirium  tremens.  Tremor  and  muscular  twitchings  of  the 
face  and  extremities  are  sometimes  observed.  Several  times  I  have  noted 
the  first  manifestations  of  approaching  meningeal  tuberculosis  to  be 
tremor  and  twitching  of  the  extremities  in  the  absence  of  all  subjective 
symptoms. 

Other  objective  signs  may  appear  long  in  advance  of  headache, 
fever,  vomiting,  or  impaired  intellect.  Inequality  and  irregularity  of 
the  pupils  may  be  the  first  indication  of  impending  meningeal  involve- 
ment. I  have  occasionally  observed  a  gradually  increasing  paralysis 
of  an  arm  and  leg  before  the  exhibition  of  other  suljjective  or  objective 
symptoms.  Ocular  and  motor  signs,  however,  do  not  supervene,  as 
a  rule,  until  after  the  subjective  manifestations  have  become  fairly 
well  defined.  At  such  times  there  may  be  noticed  inequality  of  the 
pupils  or  dilatation,  strabismus,  conjugate  deviation,  optic  neuritis, 
and  ocular  palsies.  Choroidal  tubercle  is  sometimes  recognized.  The 
•stiffness  of  the  neck  becomes  marked,  and  the  head  greatly  reti-acted. 
There  may  be  monoplegia  or  hemiplegia.  In  some  cases  tetanic 
contraction  of  a  limb  may  take  place.  Kernig's  sign  is  usually  pi'esent, 
consisting  of  failure  to  extend  the  leg  upon  the  thigh,  which  is  in  turn 
flexed  upon  the  abdomen.  The  pulse  may  be  slow,  and  of  high  tension, 
or  rapid  and  irregular. 

The  duration  is  varial)le,   death  taking  ])lace  within  a  few  days, 


340  COMPLICATIONS 

or  the  course  may  be  protracted  throughout  a  period  of  many  weeks. 
There  is  frequently  observed  a  relation  between  the  manner  of  onset 
and  the  subsequent  type  of  the  disease,  cases  with  initial  acute  symp- 
toms usually  pursuing  a  violent  and  rapid  course.  It  sometimes 
happens,  however,  that  even  cases  with  insidious  onset  later  de\'elop 
acute  symptoms  and  terminate  abruptly.  It  will  be  seen  that  the 
general  clinical  picture  of  meningeal  tuberculosis,  even  among  adults, 
is  subject  to  great  variation. 

Symptoms  in  Children  from  Two  to  Six  Years  of  Age. — At  this 
period  of  life  the  early  symptoms  are  always  subjective  rather  than 
objective  in  character.  The  onset  may  be  comparatively  sudden, 
with  violent  manifestations,  or  the  acute  symptoms  may  be  preceded 
by  a  prodromal  period  of  one  or  two  weeks'  duration.  In  some  cases 
they  are  shortly  antedated  by  a  fall  or  by  an  acute  infectious  disturbance, 
as  measles,  influenza,  or  whooping-cough.  These  premonitory  symp- 
toms are  more  or  less  ill  defined,  and  consist  of  impaired  appetite,  pallor, 
loss  of  weight,  peevishness,  irritability,  disturbed  sleep,  and  sometimes 
a  perceptil)le  change  in  disposition.  Severe  gastro-intestinal  distur- 
bances often  accompany  the  onset.  There  may  be  a  slight  irregular 
elevation  of  temperature  in  the  very  early  stages.  As  a  rule,  there  is 
not  noted  any  invariable  change  in  the  character  of  the  pulse  at  this 
time.  The  early  attention  of  the  parents  is  attracted  chiefly  to  the 
restlessness  and  appearance  of  fatigue,  with  pallor  and  emaciation. 
Usually  by  the  end  of  a  week  more  acute  symptoms  are  observed. 
Vomiting"  is  very  common,  is  occasionally  expulsive  in  character,  and 
often  has  no  connection  with  the  ingestion  of  food.  The  temperature 
is  found  to  be  moderately  elevated,  and  the  child  is  seen  to  put  the 
hand  to  the  head  as  if  in  pain.  Headache  is  the  most  important  symp- 
tom concerning  which  complaint  is  made.  This,  with  vomiting  and 
fever,  often  independent  of  prodromal  manifestations,  is  sufficient 
to  awaken  suspicion  concerning  the  possible  nature  of  the  condition. 
The  disquietude  of  the  physician  is  much  intensified  if  these  symptoms 
are  found  to  supervene  immediately  after  the  prodromal  manifestations 
which  have  been  described.  In  some  cases  the  onset  may  be  still  more 
abrupt,  the  first  symptoms  referable  to  the  condition  consisting  of 
convulsions,  which  may  recur  at  intervals. 

After  the  lapse  of  several  days  the  general  symptoms  become  more 
pronounced.  The  rate  of  the  pulse  is  not  accelerated,  as  a  rule,  but 
is  often  irregular.  A  slow  and  irregular  pulse  in  connection  with  other 
symptoms  is  of  much  importance  in  diagnosis.  While  fever  is  not  always 
present,  the  temperature  in  most  cases  is  elevated  to  a  moderate  extent, 
but  seldom  is  there  observed  any  distinct  periodicity  attending  its  rise. 
There  is  often  fever  at  one  hour  of  the  day  and  a  normal  or  subnormal 
temperature  at  other  times.  It  is  sometimes  present  in  the  morning 
and  absent  in  the  afternoon.  In  some  cases  the  fever  is  continuous  for 
several  days,  and  is  followed  by  a  brief  recession,  only  to  rise  subse- 
quently in  the  cour.se  of  the  disease.  Occasionally  the  respirations  are 
irregular  and  even  .sighing  in  character,  but  change  in  this  respect  is  not 
a  factor  of  especial  clinical  moment.  The  restlessness,  pallor,  loss 
of  strength  and  weight  progressively  increase.  The  child  becomes 
extremely  irritable,  and  cries  upon  the  slightest  provocation  and  often 
without  any  assignable  cause.  The  least  change  in  the  position  of  the 
patient  is  usuallj^  sufficient  to  provoke  a  scream,  which  appears  to  be 


THE    MENINGEAL    FORM  341 

occasioned  by  pain  in  the  head.  A  sudden  jar  in  the  room,  as  the  closing 
of  a  door  or  window,  falling  of  a  book,  moving  of  a  chair  or  the  bed, 
adjusting  the  clothing  or  even  a  window-shade,  may  disturb  the  child 
and  incite  a  pitiful  cry.  The  screaming,  however,  is  often  independent 
of  external  causes,  and  occurs,  as  a  rule,  in  paroxysms,  which  are  fol- 
lowed by  lulls  of  short  duration.  In  exceptional  cases  it  becomes  con- 
tinuous until  the  child  is  relieved  by  opiates.  The  cry,  which  is  of 
peculiar  character,  is  regarded  as  especially  suggestive  of  tuberculous 
meningitis,  and  for  many  years  has  been  described  as  the  hydro- 
cephalic cry.  The  facial  appearance  of  the  child  is  often  quite  as  charac- 
teristic as  the  cry,  though  extremely  difficult  of  descrijition.  The 
features  are  more  or  less  drawn  and  pallid,  the  expression  anxious  and 
appealing.  In  early  stages  nothing  remarkable  may  be  noted  in  the 
eyes,  but  on  account  of  the  emaciation,  they  may  appear  to  be  unusually 
large.  The  pupils  may  be  contracted,  dilated,  unequal,  or  show  no 
change  whatever.  It  is  not  uncommon  to  find  them  equally  contracted 
at  this  time.  Sleep  is  short  and  fitful,  may  be  accompanied  by  moaning, 
and  is  often  interrupted  by  sudden  screams,  the  child  apparently 
awakening  in  extreme  terror.  Twitching  or  jerking  of  the  extremities 
is  frequently  observed  during  sleep.  Physical  examination  early  in  the 
course  of  the  disease  is  negative,  objective  signs  not  being  discovered, 
as  a  rule,  until  the  irritative  stage  has  passed.  As  the  disease  advances 
the  acute  signs  of  irritation  subside  to  a  great  extent,  and  the  child 
becomes  dull  and  heavy.  Headache  no  longer  is  complained  of,  and 
the  screams  materially  diminish  in  frequency  and  severity.  There 
develops,  on  the  other  hand,  a  distinct  apathy  with  indifference  to 
surroundings.  Noises  cease  to  disturb,  sleep  is  profound,  and  it  is 
often  difficult  to  arouse  the  patient.  Delirium  sometimes  supervenes. 
The  bowels  are  constipated,  and  the  abdomen  retracted  in  many 
cases. 

Considerable  importance  has  been  attached  by  some  observers  to 
the  existence  of  the  tcwhe  ca-ebrale  upon  the  skin  of  the  abdomen,  but 
its  import  has  been  greatly  exaggerated.  The  vomiting  is  now  less 
frequent,  and  may  disappear  altogether.  The  patient  no  longer  is  able 
to  sit  up  in  bed  unless  supported,  and  is  inclined  to  rest  quietly  upon 
the  side.  The  head  may  become  noticeably  retracted,  and  the  neck 
stiffened  to  an  appreciable  extent.  Inequality  of  the  pupils  may  now 
be  noticed,  together  with  strabismus.  Ptosis  and  nystagmus  may 
exist,  and  the  pupils  may  not  react  to  light.  Kernia's  siirn.  pre- 
viously described,  is  possessed  of  great  diagnostic  ^i'^nilic-iin-c.  Hab- 
inski's  sign  is  also  of  con.siderable  importance,  cdii-i^i  m-  ul  c\ten- 
sion  of  the  great  toe,  instead  of  the  normal  flexion  ujiuii  s(  laU  liing  the 
sole  of  the  foot.  In  the  last  .stages  of  the  disease  the  .symptoms  are 
not  especially  different  from  those  already  enumerated  in  connection 
with  meningeal  tuljerculosis  of  adults.  The  stupor  increases  to  the 
point  of  coma.  After  this  has  become  established,  consciousness 
is  rarely,  if  ever,  restored,  although  the  child  may  linger  for  many  days. 
Moaning  or  muttering  delirium  during  the  comatose  state  is  less  often 
observed  in  children  of  this  age  than  in  adults.  From  my  own  observa- 
tion I  am  inclined  to  think  there  is  less  tendency  toward  picking  of  the 
bed-clothes  or  waving  of  the  hand  in  front  of  the  face.  Conjugate 
deviation  is  often  noted,  and  optic  neuritis  not  infrequently  occurs. 
The   ghastliness   of   the   picture   is   increased   by    the    upturned    eye- 


342  COMPLICATIONS 

balls  and  the  partially  closed  lids.  Retraction  of  the  head  becomes 
more  pronounced.  Twitching  of  the  facial  muscles  sometimes  takes 
place,  together  with  spasmodic  contractions  of  the  limbs  of  one 
side.  Complete  paralysis  of  certain  parts  may  develop — frequentlj- 
an  arm  and  a  leg  of  the  same  side.  The  pulse  is  now  extremely  rapid, 
and  dissolution  appears  very  imminent.  It  is  surprising,  however, 
how  long  the  patient  may  persist  in  an  apparently  moribund  condition. 
Several  times  I  have  seen  a  week  or  ten  days  elapse  after  the  develop- 
ment of  coma  before  death. 

Symptoms  in  Infants. — An  essential  difference  between  the  symp- 
toms of  meningeal  tuberculosis  in  infancy  and  childhood  is  the  more 
sudden  on.set  in  the  former,  and  the  greater  frequency  of  initial  convul- 
sions. It  has  been  stated  by  certain  observers  that  some  of  the  important 
features  in  the  differential  diagnosis  of  meningeal  tuberculosis  and 
cerebrospinal  meningitis  are  the  more  sudden  development  in  the 
cerebrospinal  cases,  the  greater  violence  of  the  sj^mptoms,  and  the 
shorter  duration  of  the  disease.  This  relation  hardly  obtains  in  the 
meningitis  of  infants,  as  the  onset  of  meningeal  tuberculosis  in  such 
patients  is  often  extremely  abrupt,  and  the  course  short  and  violent. 
On  the  other  hand,  the  ilevelopment  of  cerebrospinal  meningitis  is 
sometimes  slow  and  indefinite,  with  a  subsequent  protracted  course. 
Morse  has  recently  called  attention  to  this  interesting  comparison  in  a 
class  of  forty  cases  of  meningitis  in  infancy,  equally  divided  between  the 
tuberculous  and  the  cerebrospinal  forms.  His  diagnosis  was  made  in 
each  instance  by  autopsy  or  lumbar  puncture.  The  duration  of  the 
disease  in  his  tuberculous  cases  varied  from  one  to  forty-four  days; 
in  the  cerebrospinal,  from  seven  days  to  six  months.  The  majority 
of  the  tuberculous  cases  lasted  from  six  to  fourteen  days,  and  the 
cerebrospinal,  from  seven  days  to  several  weeks.  A  slow  pulse  is  some- 
what less  likely  to  be  observed  in  infancy  than  in  childhood,  as  is  also 
a  slow  respiration.  The  so-called  stage  of  irritation  is  also  shorter  as 
a  general  rule. 

Initial  restlessness  is  less  pronounced,  while  apathj-,  stupor,  and 
unconsciousness  develop  earlier.  I  am  inclined  to  believe  that  strabis- 
mus is  more  frequent  in  infants  than  at  a  later  time  of  life.  The  fontanel 
may  be  closed,  level,  or  elevated  in  meningeal  tubercidosis  of  infants, 
or  may  vary  from  time  to  time.  Morse  especially  emphasizes,  in  his 
analysis  of  cases,  the  marked  similarity  of  the  symptoms  in  the  menin- 
geal and  cerebrospinal  forms.  Aside  from  the  fact  that  the  general 
condition  of  the  patients  was  somewhat  better  in  the  cerelnospinal 
variety  of  meningitis,  no  very  essential  difference  was  noted  in  other 
symptoms.  The  temperature,  pulse,  respiration,  gastro-inte.stinal  lUs- 
turbances,  pain,  convulsions,  condition  of  eyes  and  abdominal  muscles 
were  practically  the  same.  \^Tiile  the  rigidity  of  the  neck  ami 
retraction  of  the  head,  as  well  as  paralysis  and  siiasni  of  the  extremi- 
ties, were  somewhat  more  constant  in  the  ccivlird^iMnal  cases,  no 
important  differences  sufficient  to  justify  a  difiin  n' i  il  ri,i;;uosis  were 
observed.  Among  other  symptoms  common  tu  thf  tuo  tUseases  in 
infants  were  noted  rapidity  of  the  pulse  and  respiration,  the  relative 
infrequency  of  excessive  vomiting,  constipation,  and  manifestations  of 
pain. 

Differential  Diagnosis. — Koplik  has  completed  an  analysis  of 
fifty-two    ca.ses   of   tulierculous   meningitis,    the   diagnosis   being   con- 


THE    MENINGEAL    P'ORM  343 

firmed  by  lumbar  puncture,  autopsy,  or  animal  inoculation.  He 
emphasizes  the  significance  of  low  temperature,  the  absence  of  hyper- 
esthesia, of  herpes  or  petechia,  the  presence  of  optic  neuritis  or  choroidal 
tubercle,  and  the  importance  of  skull  percussion  for  the  detection  of 
hydrocephalus.  From  the  reports  of  most  clinical  observers  it  would 
appear  that  in  tuberculous  meningitis  the  temperature  is  seldom  elevated 
to  a  marked  degree,  particularly  in  early  stages,  while  cerebrospinal 
meningitis,  especially  the  epidemic  form,  is  characterized  by  an  abrupt 
onset  and  high  fever. 

The  meningeal  tuberculosis  of  babies,  however,  fails  to  conform  to  the 
type  of  symptoms  in  childhood,  which  has  often  been  assumed  to  represent 
the  standard  for  all  cases  in  early  life.  Differential  diagnosis  between 
tuberculous  and  cerebrosfinal  meningitis  in  infancy  is  practically  im- 
posisible  upon  the  basis  of  the  clinical  symptoms,  and  can  he  deter- 
mined with  accuracy  only  by  examination  of  the  cerebrospinal  fluid 
obtained  by  lumbar  puncture.  An  excess  of  mononuclear  cells  is 
characteristic  of  the  tuberculous  form,  while  a  predominance  of  poly- 
nuclear  cells  suggests  the  probability  of  the  cerebrospinal  variety. 
Tubercle  bacilli  and  meningococci  are  sometimes  discovered.  The 
historj'  of  exposure  to  tuberculous  infection  affords  provisional  evidence 
as  to  the  nature  of  the  disease.  There  is  no  condition  presenting 
greater  opportunity  for  errors  of  diagnosis  than  meningeal  tuberculosis 
in  infants.  From  a  considerable  experience  with  such  cases  and  other 
affections  closely  simulating  this  disease  I  am  impelled  to  urge  the 
withholding  of  a  positive  diagnosis  prior  to  the  performance  of  lumbar 
puncture.  No  matter  how  desperate  the  condition  or  how  apparently 
conclusive  the  diagnosis  upon  the  basis  of  the  subjective  and  objective 
signs,  its  unreliability  has  been  demonstrated  all  too  frequently  by  an 
experience  not  altogether  agreeable.  It  is  inadvisable  to  withhold 
indefinitely  from  the  family  the  nature  of  one's  suspicions  regarding  the 
gravity  of  the  condition,  Init  it  is  often  inox])edient  to  render  an  al)so- 
lutely  unqualified  diagnosis.  The  nicdica]  attendant  may  occupy  but 
few  moi-e  unpleasant  positions  tluiii  obtain  when  presuming  to  diagnose 
and  prognosticate  unfavoralily  a  case  of  supposed  meningeal  tuberculosis, 
which  eventually  proceeds  to  complete  recovery.  The  evidence  is  irrefut- 
able either  that  other  conditions  so  closely  simulate  meningeal  tuberculosis 
in  infants  as  to  preclude  a  positive  diagnosis  save  on  the  basis  of  lumbar 
puncture,  or  that  a  few  cases  of  tuberculous  meningitis  unquestionably  re- 
cover. The  opportunities  for  error  in  diagnosis  were  much  greater  in  foi'mer 
years  than  at  the  present  time,  when  the  iiic(lic;il  jittcixlant  is  pii\il("<ied 
to  utilize  such  chagnostic  aids  as  the  Wid;il  Icsl  lor  t yiilioid,  the  ircoiini- 
tion  of  the  malarial  plasmochum,  the  (IctciiniiKitidii  ol'  leukocytosis, 
the  culture  test  for  influenza  bacilli,  and  examin;i,ti(in  of  tlie  (■erel)ro- 
spinal  fluid  for  lymphocytes  and  tubercle  bacilli  in  tulierculous  cases. 
and  for  meningococci  and  polynuclear  cells  in  the  cerebrospinal 
variety. 

Young  children  previously  living  in  malarial  regions,  upon  removal 
to  northern  localities,  have  been  known  to  present  symptoms  at  first 
strongly  suggestive  of  meningeal  tuberculosis.  It  is  often  possible 
in  such  cases  to  recognize,  upon  close  observation,  a  certain  periodicity 
in  the  temperature  elevation.  All- doubt,  however,  may  be  removed 
by  the  examination  of  the  blood. 

There  is  no  condition  so  frequently  mistaken  for  meningeal  tuber- 


344  COMPLICATIONS 

culosis  as  typhoid  fever.  In  man}-  cases  it  is  impossible,  upon  the 
score  of  the  general  symptomatology,  to  differentiate  accuratel}'  in 
infants  between  this  disease  and  meningeal  tuberculosis.  In  cases  of 
typhoid  complicated  by  actual  meningitis  or  characterized  by  functional 
or  toxemic  meningeal  cUsturbunce  the  chagnosis  is  well-nigh  impossible 
unless  the  mecUcal  attendant  takes  advantage  of  such  special  cUagnostic 
methods  as  examinations  of  the  blood  and  the  cerebrospinal  fluid. 
I  recollect  a  case  seen  in  consultation  some  twelve  years  ago.  The 
patient  was  an  infant  between  one  and  two  years  of  age.  A  diagnosis 
of  typhoid  fever  had  been  made  by  an  unusually  skilful  clinician.  The 
consultation  occurred  late  in  the  afternoon,  the  child  not  having  been 
seen  by  the  medical  attendant  since  morning.  In  the  mean  time  the 
condition  had  grown  progressively  worse,  and  the  child  had  lapsed 
into  unconsciousness.  The  patient  was  found  lying  upon  the  side, 
with  the  head  much  retracted,  the  neck  extremely  rigid,  and  presenting 
other  symptoms  characteristic  of  meningeal  tuberculosis.  In  view  of 
the  complete  transformation  in  the  clinical  appearance,  the  medical 
attendant  was  quick  to  rever.se  his  diagnosis,  and  stated  to  the  family 
that  the  conchtion  was  one  of  unquestionable  tuberculous  meningitis 
and  hence  entirely  hopeless.  It  appeared  from  the  available  e\idence: 
first,  that  the  symptoms  were  precisely  typical  of  meningeal  tuberculosis, 
and  that  perhaps  the  preponderance  of  evidence  pointed  toward  this 
cUsea.se;  second!}',  there  were  no  methods  of  precision  to  estaUish 
beyond  all  possible  doubt  that  the  conchtion  was  not,  after  all,  typhoid 
fever.  Inasmuch  as  I  had  previously  observed  similar  cases  presenting 
almost  conclusive  evidence  of  meningeal  tuberculosis  which  subsequently 
proved  to  be  typhoid,  it  was  apparent  that  although  there  was  every 
reason  for  the  utmost  concern  whatever  the  diagnosis,  it  was  quite 
impossible  to  affirm  absolutely  that  the  condition  was  meningeal 
tuberculosis  and  necessarily  fatal.  AccorcUngly,  I  declined  to  offer  a 
positive  diagnosis  both  on  account  of  the  practical  correctness  of  this 
position,  and  also  because  it  appeared  that  if  there  was  the  slightest 
reason  for  doubt,  the  grief-stricken  parents  were  entitled  to  the  faint 
hope  arising  from  a  withheld  opinion.  This  \'iew  seemed  to  be  correct, 
and  was  based  upon  the  fact  that  many  times  the  unexpected  is  found 
to  happen.  A  few  hours  later  an  eminent  neurologist  saw  the  patient 
in  my  absence,  and  made  an  unqualified  diagnosis  of  tuberculous  mening- 
itis, and  refused  to  concede  the  remotest  possibility  of  other  chsease  or 
of  recovery.  The  child,  after  lingering  apparently  in  a  hopeless  con- 
dition for  several  days,  finally  cUsplayed  typical  symptoms  of  typhoid 
fever,  from  which  he  eventually  recovered.  The  case  is  cited  to  illus- 
trate not  only  the  difficulty,  before  the  days  of  special  aids,  in  differen- 
tiating accurately  between  meningeal  tuberculosis  and  typhoid  fever 
in  infants,  Ijut  also  to  emphasize  the  expediency  of  reserv-ing  a  positive 
opinion  in  cases  of  possible  doubi 

The  toxemia  of  pneumonia  is  sometimes  so  great  as  to  produce  symp- 
toms distinctly  referable  to  the  meninges.  In  little  children  there  is 
often  absence  of  cough,  and  the  sudden  onset  may  be  characterized 
by  a  convulsion.  The  elevation  of  temperature,  the  early  restlessness, 
and  the  speedy  development  of  drowsiness  and  coma  at  times  may 
clo.sely  simulate  meningeal  tuberculosis.  Errors  of  diagnosis  may  be 
avoided  only  by  detailed  examination  of  the  chest.  In  such  cases  care- 
ful search  must  be  made  for  small  localized  patches  of  pneumonia,  which 


THE    MEXIXGEAL    FORM  345 

are  often  separated  from  one  another  by  intervening  areas  of  normal  or 
emphysematous  pulmonary  tissue,  obscuring,  save  in  the  hands  of  a 
skilled  examiner,  the  evidences  of  pneumonic  involvement.  I  have 
observed  in  croupous  pneumonia  profound  toxic  disturbances  strongly 
suggestive  of  meningeal  tuberculosis  in  little  patients,  when  the  physical 
signs  were  at  first  entirely  absent,  but  appeared  after  several  days  in 
a  small,  sharply  localized  area.  Too  much  stress  cannot  be  laid  upon 
the  precaution,  in  doubtful  cases,  to  examine  every  portion  of  the  chest 
at  short  intervals. 

Influenza  in  infants  is  very  rarely  attended  with  such  systemic 
disturbance  as  to  render  possible  its  confusion  with  meningeal  tuberculo- 
sis, yet  cases  may  exhijjit  sufficient  toxemia  to  afford  uneasiness  as  to 
the  actual  condition.  A  year  ago  I  saw  in  consultation  an  infant  pre- 
senting such  a  group  of  symptoms  as  to  justify  a  reasonable  suspicion 
concerning  the  existence  of  meningeal  tuberculosis,  especially  in  view 
of  a  negative  pulmonary  examination  and  a  persistence  of  profound 
stupor  for  nearly  a  week.  A  provisional  diagnosis  of  meningeal  tuber- 
culosis had  previously  been  rendered.  Lumbar  puncture  not  having 
been  performed,  I  was  impelled  to  recognize  the  possibility  of  an  unus- 
ually severe  influenza  infection,  which  was  then  prevalent  in  epidemic 
foi'm.     This  diagnosis  subsequently  proved  to  be  correct. 

Acute  intestinal  toxemia  in  children  may  simulate  closely  meningeal 
tuberculosis.  The  onset  is  sudden ,  and  there  is  often  present  intense  pain 
in  the  head.  The  temperature  is  invariably  elevated  and  the  patient 
is  profoundly  prostrated.  As  a  rule,  there  is  exhibited  considerable 
stupor  and  the  general  clinical  manifestations  of  a  severe  infection. 
For  several  days  the  possibility  of  acute  tuberculous  meningitis  in  such 
cases  can  be  excluded  only  by  close  clinical  observation. 

Middle-ear  disease,  whether  or  not  tuberculous,  sometimes  presents 
a  group  of  symptoms  rendering  the  condition  impossible  of  differentia- 
tion from  meningeal  tuberculosis,  save  upon  careful  otologic  exami- 
nation. Suppuration  of  the  middle  ear  may  even  produce  optic 
neuritis.  Nothing  can  be  more  embarrassing  to  the  medical  attend- 
ant after  an  anxious  period  of  observation  than  to  pronounce  a  diagnosis 
of  meningeal  tuberculosis,  and  subsequently  note  an  immediate  remis- 
sion of  the  symptoms  upon  rupture  of  the  membrane  and  evacuation  of 
the  pus. 

Without  the  means  of  securing  precise  diagnostic  data  through 
recourse  to  lumbar  puncture,  experience  has  shown,  as  stated,  either 
that  cases  of  meningeal  tulserculosis  actually  recover,  or  that  the  chsease 
is  simulated  so  closely  by  other  conditions  as  to  preclude  accurate  differ- 
entiation. I  have  in  mind  two  interesting  and  illustrative  cases  from 
my  experience.  The  first  was  ol>s(M-vf'd  al)out  twelve  years  ago.  The 
patient  was  an  infant  in  arms,  the  iiiolhcr  liciiit;-  (wticniely  tlelicate  and 
the  father  a  victim  of  pulmonary  tulierculdsis  of  sc\eral  years'  standing. 
The  child  displayed  typical  symptoms  of  meningeal  tuberculosis,  there 
being  much  wasting  of  the  tissues,  pronounced  pallor  with  repugnance 
to  food,  great  irritability  and  peevishness,  and  the  characteristic  hydro- 
cephalic cry.  There  were  retraction  of  the  head,  stiffness  of  the  neck, 
and  other  symptoms  of  such  a  nature  as  to  suggest  almost  beyond  ques- 
tion the  probability  of  meningeal  tuberculosis.  A  provisional  diagnosis 
to  this  effect  was  made  by  Dr.  H.  T.  Pershing  and  myself,  but  an  abso- 
lutely unfavorable  prognosis  was  not  rendered  for  reasons  previously 


346  COxMPLRATIOXS 

outlined.  The  child  made  an  eventual  recovery,  though  developing 
shortly  afterward  caries  of  the  upper  dorsal  vertebra'. 

The  other  case  was  observed  in  July,  1906,  the  patient  being  a  boy 
of  four  years,  whose  mother  was  exceptionalh-  frail  and  the  father  tuber- 
culous for  several  years.  The  illness  occurred  at  a  time  when  the  family 
was  sojourning  for  the  summer  in  the  mountains  of  Colorailo,  far  removed 
from  easy  communication.  The  child  had  been  delicate  for  months, 
poorly  nourished,  and  exceptionally  pale.  Sleep  and  digestion  had  been 
disturbed,  and  the  appetite  capricious.  After  a  prodromal  period  of 
peevishness  and  irritability  the  child  developed  fever,  with  vomiting 
and  exceptionally  .severe  headache.  Physical  examination  was  entirely- 
negative,  even  to  absence  of  .splenic  enlargement.  The  Widal  test, 
several  times  employed,  was  invariably  negative,  as  was  also  the  search 
for  the  malarial  plasmochum.  The  early  restlessness  was  succeeded  by 
beginning  drowsiness  and  stupor.  The  temperature  remained  persistentlj- 
elevated,  constipation  was  marked,  and  the  abdomen  was  carinated 
to  a  pronounced  degree.  The  headache  continued  until  stupor  was  well 
established.  The  loss  of  weight  was  very  rapid,  and  the  child  speedily 
presented  a  much  emaciated  appearance.  Mild  delirium  was  present, 
with  retraction  of  the  head  and  marked  stiffening  of  the  neck.  Kernig's 
and  Babinski's  signs  were  present,  together  with  inequality  of  the  pupils 
and  conjugate  deviation.  Lumbar  puncture  was  not  emploved,  as  this 
was  considered  hardly  necessary  for  the  establishment  of  a  diagnosis 
which  seemed  almost  incontrovertible.  A  month  of  the  utmo.st  anxiety 
was  passed  in  efforts  to  support  the  child  with  concentrated  liquid 
nourishment.  Upon  the  gradual  subsidence  of  the  fever  the  patient  was 
greatly  prostrated  for  many  weeks.  He  was  unable  to  sit  up  in  laed.  ami 
stiffness  of  the  neck  and  retraction  of  the  head  persisted  for  several 
weeks.  The  sub.sequent  convalescence  w-as  slow,  but  progressive. 
Kernig's  and  Babinski's  signs  disappeared  completely,  and  the  child 
was  finally  able  to  walk,  although  this  was  accomplished  at  first  with 
the  utmost  difficulty,  the  locomotion  being  distinctly  ataxic.  There 
was  inability  to  coorchnate  the  movements  of  the  lower  limbs,  and  a 
perceptible  dragging  of  the  toes.  This  gratlually  improved  following 
the  employment  of  massage,  strychnin,  and  potassium  iodid,  although 
to  what  extent  these  measures  were  of  practical  benefit  it  is  impossible 
to  state.  If  this  was  not  a  case  of  meningeal  tuberculosis,  it  was,  to  say 
the  least,  a  condition  which  I  was  unable  to  diagnose.  The  lesson  to  be 
learned  from  such  an  experience  is  to  the  effect  that  no  matter  how 
apparently  hopeless  the  condition  and  how  definite  the  diagnosis,  the 
physician,  in  deference  to  his  responsible  trust,  should  refrain  from 
assuming  the  hopelessness  of  despair,  but  should  hold  in  reserve  to  the 
very  end  an  abicUng  faith  in  the  possibilitii  of  recover}'. 

The  treatment  of  all  cases  of  miliary  tuberculosis,  whether  of  the 
pulmonary,  typhoidal,  or  meningeal  variety,  and  entirely  regardless  of 
age,  must  be  almost  entirely  symptomatic  in  character.  Authentic 
reports  are  recorded  of  highly  gratifying  results  following  repeated 
lumbar  puncture  in  tuberculous  meningitis.  Prompt  benefit  vmdoubt- 
edly  may  occasionally  he  obtained  upon  remo\-al  of  the  cerelirospinal 
fluid,  which,  according  to  some  ob-servers.  should  be  allowed  to  escape 
until  the  flow  ceases  spontaneously.  Several  cases  of  complete  recovery 
have  been  reported  despite  the  demonstrated  presence  of  bacilli  in  the 
withdrawn  fluid.     This  would  appear  to  be  possible,  particularly  when 


INTRODUCTION  347 

bacilli  of  attenuated  virulence  are  found.  Piebold  has  reported  a  case 
of  tuberculous  meningitis  in  a  girl  of  sixteen  years,  with  a  favorable 
termination,  after  two  months'  illness.  Lumbar  puncture  was  per- 
formed daily  during  the  first  two  weeks,  and  twenty-four  times  alto- 
gether. A  total  of  574  c.c.  of  cerebrospinal  fluid  containing  tubercle 
bacilli  was  removed.  While  I  have  not  made  personal  use  of  lumbar 
puncture  for  other  than  diagnostic  purposes,  some  evidence  of  its  thera- 
peutic utility  in  occasional  instances  has  been  reported. 


SECTION    II 
Tuberculosis  of  the  Pleura 


INTRODUCTION 

The  various  forms  of  miliary  tuberculosis  have  been  described  as 
resulting  from  the  direct  distribution  of  bacilli  through  the  medium 
of  the  blood-stream,  but  infection  of  remote  parts  of  the  body  may  be  of 
distinct  hematogenous  origin  without  accompanying  evidence  of  acute 
miliary  tuberculosis.  Thus  tuberculosis  of  the  pleura,  the  peritoneum, 
larynx,  and  portions  of  the  alimentary  and  genito-urinary  tracts  may 
occur  as  a  result  of  conveyance  of  the  infection  by  means  of  the  circula- 
tion. This  does  not  imply,  however,  that  localized  tuberculous  processes 
may  not  exist  in  such  organs  and  tissues  by  reason  of  some  other  method 
of  bacillary  invasion.  Tuberculosis  of  certain  organs  may  take  place 
in  some  instances  by  reason  of  hematogenous  invasion,  but  bacilli  may 
be  conveyed  to  the  same  portion  of  the  body  by  means  of  the  lym- 
phatics, by  direct  contact  with  infected  secretions,  and,  finally,  by 
extension  of  the  tuberculous  process  from  immediately  contiguous 
tissue.  Tuberculous  processes  in  remote  portions,  occnniiiu  ///  (onncc- 
tion  with  acute  general  miliary  tuberculosis,  are  of  but  iiilliim  i  liiiical 
importance,  as  the  patient  usually  dies  long  before  e-\ti-iisi\c  changes 
are  permitted  to  take  place. 

In  view  of  the  foregoing  considerations  it  scarcely  seems  practicable 
to  attempt  the  classification  of  the  various  disseminated  tuberculous 
processes  solely  according  to  the  preci.se  method  of  bacillary  trans- 
mission. The  complicating  tuberculous  conchtions  in  different  regions, 
irrespective  of  their  mode  of  invasion,  will  be  considered,  therefore, 
somewhat  in  the  order  of  their  relative  importaiui'  ami  fr<<nienc}-. 

Tuberculosis  of  the  serous  membranes  is  of  esscnt  iai  mn  rest,  emlirac- 
ing  the  involvement  of  the  pleura,  pericardium,  ami  iicrituneum.  Of 
the.se.  the  first  named  is  the  most  important  on  account  of  its  frequency 
and  modifying  effect  upon  prognosis. 


348  COMPLICATIONS 


CHAPTER  XLIX 


ETIOLOGY  AND  PATHOLOGY  OF  TUBERCULOUS 

PLEURISIES 

Ix  dcalinj;  with  the  plcuial  riiiii|iliratic)ns  of  pulmonary  tuberculosis, 
it  is  well  to  tliscriiiiiiiaic  liciwcni  iiiln'iculous  infections  of  the  serous 
membrane  and  the  \'a.iii>iis  iiit rapl^ural  romlitions  due  to  other  causes, 
yet  coexisting  with  the  pulmomu}  inlcriicii  and  exercising  a  powerful 
influence  upon  prognosis.  The  tlistiimiii<liiii^  features  between  tuber- 
culous and  non-tuberculous  invohcnicnts  ui  the  pleura  accompanying 
pulmonary  tuberculosis  are  often  of  bacteriologic  and  pathologic 
interest,  rather  than  of  especial  clinical  importance.  At  times  it  is 
exceedingly  difficult  to  differentiate  between  them  even  by  animal 
experimentation.  It  may  afford  greater  clearness  to  consider,  first,  the 
etiologic  relations  of  tuberculous  pleurisies  and,  secondl}-,  the  essential 
clinical  features  of  intrapleural  complications  in  general. 

Tuberculosis  of  the  pleura  is  almost  always  secondary  to  infection 
in  some  other  portion  of  the  body,  although  it  is  often  impossible  to 
discover  the  primary  source.  Failure  to  do  this  offers  no  valid  argu- 
ment in  favor  of  primarj'  infection.  The  tubercle  deposit  may  be  the 
result  of  direct  extension  from  the  lung,  or  the  infection  may  be  conve3'ed 
from  a  bronchial  gland  by  means  of  the  lymphatics.  In  some  instances 
it  is  known  to  exist  as  a  type  of  miliary  invasion  without  pulmonary 
infection.  This  form  is  often  quite  benign  in  character,  and  has  been 
fotmd  to  be  more  common  than  was  formerly  believed  to  be  the  case. 
The  more  frequent  method  of  pleural  invasion  consists  of  direct  pul- 
monary extension,  the  focus  from  which  emanates  the  pleural  infection 
being  superficially  located  in  close  proximity  to  the  serous  covering. 
In  such  cases  certain  pathologic  changes  are  prone  to  take  place  in  the 
pleura  prior  to  the  deposit  of  tubercle.  The  initial  hyperemia  of  the 
serous  membrane,  with  accompanjang  superficial  roughness  incident  to 
fibrinous  transudation,  may  be  sufficiently  inflammatory  in  nature  to 
proiluce  small  points  of  adhesion  between  the  opposing  surfaces.  When 
the  microorganisms,  however,  gain  early  and  rapid  entrance  into  the 
pleural  cavity,  the  resulting  inflammation  is  much  more  extensive,  and 
localized  adhesions,  as  a  rule,  do  not  take  place. 

Trauma  of  the  chest,  as  in  other  parts  of  the  body,  is  often  the 
starting-point  of  a  tuberculous  infection.  Its  influence  relates  to  a 
diminished  power  of  resistance  of  the  tissue-cells  against  the  bacillus. 
Prior  to  a  slight  injury  the  presence  of  bacilli  may  result  in  an  increa.sed 
phagocj^osis  which  retards  bacOlary  growth  and  development.  This 
defensive  action  is  rendered  much  less  effective  by  the  inflammatory 
condition  resulting  from  a  slight  traumatism. 

While  the  infection  is  often  conveyed  to  the  pleura  from  enlarged 
bronchial  or  mediastinal  glands,  it  has  not  been  demonstrated  that 
pleurisies  are  more  prone  to  develop  in  individuals  exhibiting  the 
so-called  scrofulous  diathesis.  Tuberculous  pleurisies  may  follow 
tuberculous  bone  affections,  as  caries  of  the  vertebra,  ribs,  or  sternum. 
In  the  same  way  the  pleura  may  l)e  invaded  bj'  the  progress  of  bacilli 
along  the  lymph-channels  from  the  peritoneum  in  cases  of  peritoneal 
infection. 


ETIOLOGY    AND    PATHOLOGY    OF   TUBERCULOUS    PLEURISIES  349 

Medical  opinion  concerning  the  frequency  of  tuberculous  involve- 
ment of  the  pleura  has  changed  much  in  recent  years.  It  may  be 
assumed  that  pleurisies  are  oftener  of  tuberculous  origin  than  was 
previously  supposed.  Twenty  years  ago  the  teaching  in  mecUcal  schools 
was  to  the  effect  that  an  exceedingly  large  proportion  of  so-called 
idiopathic  pleurisies  were  presumably  of  tuberculous  character.  The 
clinical  evidences,  since  presented,  have  tended  to  confirm  what  was 
regarded  at  that  time  as  a  reasonable  assumption.  Extreme  views  are 
entertained  by  some  observers,  who  maintain  that  practically  all  serous 
effusions  which  develop  without  explainable  cause  are  tuberculous  in 
nature.  This  position  is  vigorously  combated  by  clinicians,  who  point 
to  the  large  numljer  of  recoveries  without  subsequent  infection  in 
other  parts  of  the  body.  There  are  many  reasons  why  it  is  difficult  to 
arrive  at  strictly  accurate  conclusions  concerning  the  frequency  of 
tuberculous  pleurisies.  Even  modern  methods  of  diagnosis  are  subject 
to  necessary  limitations  and  are  often  inconclusive.  In  the  past  it 
has  been  customary  to  attach  essential  importance  to  such  clinical  data 
as  a  negative  family  history,  an  external  appearance  of  health  and 
vigor,  the  non-recognition  of  pulmonary  phthisis  or  of  tuberculous 
involvement  elsewhere,  and  the  failure  to  discover  tubercle  bacilli  in  the 
aspirated  pleural  exudate.  In  the  problem  of  diagnosis  but  compara- 
tively slight  significance  may  be  attached  to  any  or  all  of  these  negative 
factors.  Pleural  effusions  of  undoubted  tuberculous  origin  are  observed 
with  frequency  in  individvials  presenting  other  manifestations  of  per- 
fect health.  It  is  idle  in  most  cases  to  question  the  etiology  of  pleu- 
risies complicating  pulmonary  tulierculosis,  as  a  reasonable  prima  facie 
assumption  is  afforded  as  to  their  nature.  At  other  times  especial 
interest  attaches  to  the  bacteriologic  findings.  Failure  to  discover 
tubercle  bacilli  in  the  exudate  withdrawn  from  the  pleural  cavity  is 
the  rule  rather  than  the  exception.  The  very  fact  of  its  sterility  may 
be  construed  as  being  strongly  suggestive  of  its  tuberculous  character, 
for  the  absence  of  other  pathogenic  microorganisms  affords  presumptive 
evidence  that  the  cause  of  irritation  proceeds  from  tubercle  deposit. 
It  must  not  be  assumed,  however,  that  the  recognition  of  other  bacteria 
in  the  exudate  precludes  in  all  cases  the  presence  of  tubercle  liacilli. 
Pyogenic  microorganisms  may  find  their  way  into  the  plem-al  cavity 
from  pulmonary  excavations  or  mediastinal  glands,  or  they  may  be 
introduced  from  without  in  the  performance  of  aspiration.  In  this 
event  the  character  of  the  effusion  is  completely  transformed  as  regards 
its  gross  appearance,  the  pathologic  findings,  and  the  prognostic  import. 

The  frequent  inability  to  discover  bacilli  in  the  exudate  b_y  micro- 
scopic examination  is  susceptible  of  several  different  explanations.  The 
initial  tubercle  deposit  upon  the  pleural  membrane  is  often  sufficient 
to  produce  an  exudation  of  serous  fluid,  long  before  its  degeneration 
and  softening  permit  an  evacuation  of  liacilli.  Apropos  of  then-  presence 
in  comparatively  small  numbers  in  the  exudate,  it  has  been  pointed  out 
that  a  fluid  medium  inhibits  to  a  certain  extent  their  growth  and 
development.  Cornet  has  suggested  that  the  bacilli  sink  to  the  bottom 
of  the  pleural  cavity  and,  therefore,  are  rarely  withdrawn  upon  aspira- 
tion. I  am  not  sure  that  the  accuracy  of  this  statement  is  subject  to 
demonstrable  proof.  Even  were  they  pn^ne  to  gravitate  to  the  more 
dependent  portions,  it  would  appear  that  their  exit  should  be  facilitated 
upon  aspiration  bj-  the  rise  of  the  diaphragm  and  the  increased  expan- 


350  COMPLICATIONS 

sion  of  the  lung.  Attention  is  called  to  the  comparative  thoroughness 
of  aspiration  in  early  cases,  quite  irrespective  of  the  point  of  neecUe 
insertion.  Unless  a"  considerable  amount  of  liquid  is  permitted  to 
remain,  the  cavity  becomes  obliterated  to  a  great  extent.  In  the  event 
that  paracentesis  is  employed  by  means  of  trocar  and  cannula,  the 
egress  of  bacilli  is  further  enhanced  by  the  succussion  resulting  from 
the  respiratory  excursions  and  their  projective  effect. 

It  is  probable  that  in  many  instances  inability  to  detect  bacilli  in 
the  exudate  has  been  due  to  faulty  technic  in  the  preparation  of  the 
specimen.  I  am  impelled  in  part  to  this  belief  by  the  fact  that  among 
my  own  patients  bacilli  ha\-e  been  discovered  with  comparative  frequency 
in  pleural  exudates  which  have  been  submitted  to  skilled  pathologists 
for  examination.  In  doubtful  cases  the  diagnosis  may  often  be  estab- 
lished by  animal  inoculation.  A  tuberculin  reaction  has  been  obtained 
by  Debove  and  Renault  by  injecting  into  tuberculous  patients  a  portion 
of  the  filtrate  of  the  exudate.  A  recent  means  of  clinical  diagnosis  to 
which  the  term  "cytology"  is  applied,  relates  to  a  study  of  the  cellular 
elements  after  centrifuging  and  staining.  An  essential  characteristic 
of  tuberculous  effusion  is  the  great  frequency  of  lymphocytes,  which 
constitute  the  larger  portion  of  the  cells. 

A  still  more  recent  method  has  been  described  by  Jousset.  His 
process  consists  of  the  use  of  a  digestant  composed  of  pepsin,  one-half 
gram;  glycerin  and  hydrochloric  acid,  of  each,  10  c.c;  sodium  fluorid, 
3  c.c. ;  distilled  water,  1000  c.c.  The  sediment  is  inoculateil  into  animals 
after  centrifuging.  "  He  claims  by  this  method  to  find  tubercle  bacilli 
in  almost  all  cases  of  serous  pleuritic  exudate,  and  in  that  from  many 
cases  of  peritonitis' '  (Behring  and  James). 

Osier  calls  attention  to  the  fact  that,  in  order  to  make  the  test  fairly 
reliable,  a  comparatively  large  amount  of  the  fluid  exudate  must  be 
inoculated.  He  alludes  to  Eich's  result  in  inoculation  experiments, 
who  reported  62  per  cent,  as  tuberculous  upon  the  use  of  15  c.c.  of  the 
exudate,  while  0.1  per  cent,  of  his  cases  were  positive  from  the  inoculation 
of  1  c.c.  Several  of  the  French  observers  have  reported  nearly  all  their 
primary  pleurisies  to  be  demonstrably  tuberculous  in  character  by  means 
of  the  inoculation  test. 

The  difficulties  attending  a  precise  conception  concerning  the  fre- 
quency of  tuberculous  pleurisies  are  occasioned  not  only  by  neglect  to 
secure  a  definite  clinical  diagnosis,  but  as  well  by  inabilit}'  to  interpret 
accurately  the  subsequent  histories  of  affected  individuals.  Many 
patients  are  lost  sight  of  entirely,  while  others,  though  subject  to  obser- 
vation for  a  period  of  years,  do  not  afford  in  themselves  sufficient  authen- 
tic data  to  justify  important  conclusions.  In  a  series  of  cases  of  uncom- 
plicated serous  effusion  Cabot  reports  80  per  cent,  to  be  in  good  health 
after  five  years  or  more,  half  of  this  number  having  been  followed  for 
a  period  of  ten  years.  Ninety  per  cent,  were  reported  in  apparent 
health  at  the  expiration  of  two  years  or  over.  Fifteen  per  cent,  of  the 
entire  number  eventually  developed  tuberculous  jiroccsscs  in  other  parts 
of  the  body.  Three  per  cent,  exhibited  manifestations  ot  tutierculosis 
within  two  years  following  the  effusion.  He  cites,  however,  two  patients 
who  developed  a  very  rapid  form  of  tuberculosis  even  after  the  expira- 
tion of  nine  and  sixteen  years  re.spectively.  No  report  was  made  as  to 
what  percentage  of  the  entire  group  was  demonstrated  to  be  of  tuber- 
culous origin.     It  is  apparent  that  the  clinical  evidence  adduced  from 


ETIOLOGY    AND   PATHOLOGY    OF    TUBERCULOUS    PLEURISIES  351 

reference  to  the  subsequent  histories  of  these  cases  is  to  the  effect  that, 
in  the  vast  majority  of  instances,  there  was  but  little  relation  between 
the  pleural  effusion  and  the  subsequent  exhibition  of  tuberculous  mani- 
festations in  other  parts  of  the  body.  This  series  of  cases  may  be 
regarded  as  forming  the  basis  for  a  reasonable  belief  in  the  appaient 
curability  of  many  tuberculous  pleurisies,  and  in  the  infrequent  clinical 
evidence  of  extension  to  other  regions.  For  a  long  time  genuine  tuber- 
culous pleurisies  have  been  looked  upon  as  subject  to  complete  recovery 
in  many  cases.  The  type  of  pulmonary  tuberculosis  characterized  by 
initial  pleural  involvement  is  generally  conceded  to  be  one  of  the  most 
benign  forms  of  the  disease.  Incipient  tuberculous  processes  involving 
the  pleura  are  peculiarly  prone  to  imdergo  entire  arrest,  and  it  must 
not  be  assumed,  therefore,  that  a  negative  history  of  pulmonary  infec- 
tion, even  after  a  prolonged  interval  following  an  idiopathic  effusion,  is 
to  be  construed  as  a  valid  argument  against  a  possible  tuberculous  exu- 
date. Further,  after  the  lapse  of  several  years,  a  rigid  physical  examina- 
tion, though  negative  in  result,  can  scarcely  preclude  entirely  the  tuber- 
culous nature  of  the  initial  pleural  affection. 

It  is  interesting  to  note  that  Kelsch  and  Vaillard  have  reported  the 
autopsy  findings  of  sixteen  cases  of  idiopathic  pleurisy  in  which  a  com- 
plete cure  was  believed  to  have  been  secured,  yet  the  tuberculous  nature 
of  the  involvement  was  demonstrated  beyond  question.  It  is  easy  to 
conceive  of  dormant  and  quiescent  tuberculous  infections  entirely 
incapable  of  clinical  recognition  for  an  indefinite  number  of  years,  yet 
under  suitable  conditions,  susceptible  of  being  eventually  ai'oused  to 
renewed  activity. 

While  idiopathic  pleurisies,  as  a  rule,  are  characterized  by  an  appar- 
ent mildness  of  the  original  infection,  it  is  none  the  less  true  that  in 
some  instances  a  progressive  pulmonary  tuberculosis  may  subsequently 
develop.  Several  times  after  an  apparently  benign  serous  effusion  I 
have  noted  the  early  onset  of  pulmonary  symptoms  with  a  rapid  decline 
to  a  fatal  issue.  Out  of  a  total  of  2070  cases  of  pulmonary  tuberculosis 
observed  in  private  practice,  67  present  the  history  of  an  mitecedent 
serous  pleural  effusion.  In  42  the  pulmonary  symptoms  developed 
after  the  lapse  of  two  years  or  over  following  the  pleurisy;  8.  from  one 
and  one-half  to  two  years;  4,  from  one  to  one  and  one-half  years;  9,  from 
six  months  to  a  year,  and  4  slightly  under  six  months.  One  hundred  and 
twenty-six  others  referred  the  onset  of  the  pulmonary  infection  to  an 
accompanying  pleurisy.  It  is  safe  to  assume  that  an  exceechngly  large 
proportion  of  idiopathic  seions  effusions  are  actually  tuberculous  in 
character.  While  a  proloui^cd  iiciiml  of  apparent  health  in  many  cases 
indicates  a  pronounced  tendi'iM  y  tci\\;ird  spontaneous  arrest,  it  cannot 
be  regarded  as  casting  a  shallow  upon  the  probable  tuberculous  origin. 

The  pathologic  changes  incident  to  tuberculous  pleurisy  relate  to 
tubercle  formation,  inflammatory  changes,  with  or  without  effusion, 
and  fibrous  tissue  formation.  But  brief  allusion  need  be  made  to  essen- 
tial anatomic  conditions. 

In  dry  pleurisies  the  serous  membrane  is  covered  by  a  layer  of  fibri- 
nous exudation,  to  which  there  is  imparted  either  a  granular  or  a  rough, 
shaggy  appearance.  In  mild  cases  the  inflammatory  lymph  undergoes 
resolution,  and  following  its  liquefaction  is  reabsorbed  to  a  considerable 
extent.     In  other  cases  adhesions  take  place,  producing  a  union  of  the 


352  COMPLICATIONS 

opposing  membranes.  The  agglutination  of  the  pleural  surfaces  may  be 
confined  to  one  or  several  small  areas  which  correspond  to  the  fibrinous 
deposits.  In  the  event  of  extensive  and  advanced  pleural  involvement, 
and  especially  following  the  disappearance  of  an  effusion,  the  adhesions 
are  apt  to  be  more  complete  antl  permanent.  The  membranes  may 
become  glued  together  over  wide  areas,  or  there  ma}'  be  extensive  con- 
nective-tissue formation,  resulting  in  the  production  of  numerous  fibrous 
bands.  These  adhesions  are  extremel}-  tough  and  unyielding,  and  the 
pleura  moderately  thickened.  Small  tuberculous  nodules  are  scattered 
over  the  surface  of  the  memlirane  and  throughout  the  new-formed  tissue, 
in  which  cheesy  foci  are  often  emljedded.  Large  caseous  masses,  how- 
ever, are  rarely  present,  the  tubercle  deposits,  as  a  rule,  being  small  in 
size.  General  inflammation  is  not  always  noticed,  particularly  if  the 
infection  is  the  result  of  miliar}'  distribution.  In  some  instances  there 
is  an  eruption  of  gray  tubercles,  unattended  by  other  than  a  slight  local 
inflammatory  change.  If  more  or  less  diffused  inflammation  is  found 
accompanying  an  eruption  of  miliar}-  tubercles,  it  is  likely  that  the 
infection  of  the  membrane  has  resulted  from  a  tuberculous  focus  closely 
contiguous  to  the  pleura  itself,  as  caries  of  the  vertebra,  an  infected 
lymphatic  gland,  or  a  tuberculous  lung. 

The  inflammatory  change  is  often  sufficient  to  produce  an  effusion 
of  liquid  into  the  pleural  cavity.  When  this  exudative  process  is  the 
result  of  pure  tuberculous  infection,  unaccompanied  by  pyogenic  micro- 
organisms, tlie  fluid  consists  of  a  straw-colored,  transparent,  serous  accu- 
mulation. It  is  very  albuminous,  and  sometimes  capable  of  spontaneous 
coagulation,  dense,  flocculent  masses  being  suspended  in  the  exudate. 
These  masses  sink  to  the  dependent  portion  of  the  pleural  cavity,  where 
they  are  retained  as  thick,  whitish  accumulations.  The  exudate  contains 
leukocytes  and  red  blood-cells,  fibrin  shreds,  and  cells  from  the  endothe- 
lium of  the  pleura.  The  leukocytes  are  sometimes  sufficiently  numerous 
to  impart  a  distinct  turbicUty  to  the  fluid.  The  red  blood-cells  in  turn 
may  be  present  in  such  numbers  as  to  transform  serous  into  hemorrhagic 
effusions.  The  exudate  may  be  slightly  discolored  or  contain  almost 
pure  blood.  Two  years  ago  I  withdrew  by  aspiration  from  the  pleural 
cavity  of  a  tuberculous  invalid  eighteen  ounces  of  blood,  which  immedi- 
ately coagulated.  I  have  had  a  similar  experience  in  three  phthisical 
patients  in  whom  the  tuberculous  pleurisy  was  complicated  by  the 
presence  of  other  microorganisms,  notably  the  pneumococcus. 

The  quantity  of  fluid  within  the  pleural  cavity  may  vary  from 
one-half  pint  to  several  quarts.  The  effusion  is  sometimes  purulent 
in  character,  though  seldom  when  solely  of  tuberculous  origin. 
The  transition  of  a  serous  effusion  into  a  purulent  one  is  sometimes 
occasioned  by  the  introduction  of  pathogenic  microorganisms  as  the 
result  of  an  unclean  exploratory  or  aspirating  needle.  In  cases  of 
mixed  infection  the  specific  infective  agents,  cliiefly  the  streptococci, 
staphylococci,  and  pneumococci,  are  readily  found  in  the  exudate. 
Pleurisies  which  are  distinctly  purulent  from  the  beginning  rarely 
contain  tubercle  bacilli,  but  are  incident  to  such  infectious  diseases  as 
scarlet  fever,  typhoid  fever,  and  pneumonia.  Purulent  effusions  are 
peculiarly  apt  to  occur  in  children,  and  at  this  age  serous  exudates  are 
less  frequent  than  in  adults.  Among  the  latter  the  existence  of 
empyema  is  provisional  evidence  that  the  tubercle  bacillus,  though 
possibly  the   initial  exciting  cause,  is  not  the  sole  etiologic  factor.     I 


Chronic  hyperplastic  tuberculous  pleuritis  in  patient  who  died  of  miliary  tuberculosis. 
Note  the  enormous  thickening  and  congestion  of  entire  pleural  surface.  This  lung 
(left)  was  taken  from  the  same  patient  as  was  the  lung  in  Plate  3. 


SYMPTOMATOLOGY    OF   TUBERCULOUS    PLEURISY  353 

am  convinced,  from  my  own  experience,  however,  that  pure  tuberculous 
exudates  present  varying  degrees  of  cloudy  opacity  more  frequently 
than  has  been  supposed.  My  attention  was  early  attracted  to  the 
disturbing  frequency  with  which  initial  serous  fluids  were  gradually 
converted  into  semipurulent  effusions  following  a  number  of  aspirations. 
The  primary  assumption  was  entertained  that,  despite  rigid  aseptic 
precautions,  an  infection  had  been  conveyed  to  the  pleural  cavity 
simultaneously  with  the  introduction  of  the  needle.  Inasmuch,  how- 
ever, as  an  absolutely  irreproachable  needle  was  used,  the  inference  was 
reasonable  that  all  possibility  of  infection  was  obviated.  Confirmation 
of  this  belief  has  occasionally  been  found  in  the  sterile  nature  of  the 
exudate  in  successive  aspirations,  notwithstanding  its  greater  opacity 
and  increasing  number  of  leukocytes.  I  have  observed  a  few  such 
instances  of  cloudy,  though  scarcely  purulent,  effusion  in  tuberculous 
individuals  at  the  time  of  the  first  aspiration. 

While  purulent  effusions  are  sometimes  entirely  sterile,  suggesting 
the  possibility  of  a  tuberculous  origin,  the  pyogenic  microorganisms 
are  discovered  in  a  large  proportion  of  cases.  These  effusions  separate 
on  standing  into  an  upper  layer  of  yellowish-green  serum,  with  heavy 
creamy  pus  at  the  base.  The  so-called  tuberculous  empyemas  are 
rarely,  if  ever,  fetid, the  pus  usually  being  thick  and  homogeneous. 


CHAPTER  L 
SYMPTOMATOLOGY  OF  TUBERCULOUS    PLEURISY 

The  general  sym'ptomatologii  of  tuberculous  pleurisy  does  not  differ 
essentially  from  that  of  the  non-tuberculous  variety.  Inasmuch  as  the 
clinical  features  are  practically  identical,  it  is  not  designed  to  discuss  the 
symptoms  of  tuberculous  pleurisy  as  a  separate  disease,  but  to  consider 
chiefly  its  relation  to  pulmonary  phthisis.  Attention  is  called  especially 
to  the  frequency  of  intrapleural  complications  in  consumption,  and  to 
their  practical  influence  in  determining  final  results.  The  clinical  mani- 
festations referable  to  the  various  pleural  conditions  are  frequently  of 
greater  importance  than  those  dependent  upon  the  pulmonary  involve- 
ment. 

The  early  symptoms  of  pleurisy  among  consumptives  may  be  fairly 
acute  or  of  trifling  character.  In  some  cases  the  onset  is  very  insidious, 
and  entirely  devoid  of  clinical  nianifcstatidns.  In  acute  cases  the 
principal  symptom  is  pain  in  the  side,  whirh  is  usiuill>  shaip  nv  .stabbing 
in  character,  and  intensified  ujion  ilccp  rrs|iiiati(»ii  or  cough.  An 
extreme  variability  is  exhibited  in  the  degree  of  pain  experienced  by 
different  individuals.  In  some  instances  it  is  so  slight  as  to  occasion 
but  little  complaint ;  in  other  cases  it  is  very  distressing.  I  have  observed 
many  invalids  w^hose  suffering  was  most  excruciating  and  was  relieved 
only  by  large  hypodermic  doses  of  morphin.  I  recall  one  instance 
of  initial  pleural  pain  in  a  delicate  woman  whose  anguish  was  so 
extreme  as  to  demand  over  a  grain  of  morphin  in  the  course  of  a  few 
liours,  after  hot  applications,  fixation  of  the  ribs  with  tight  adhesi\e 


354  COMPLICATIONS 

strapping,  and  dry  cupping  had  not  proved  of  the  slightest  avail. 
Seldom  have  I  found  the  pain  referred  to  the  nipple,  but  in  the  majority 
of  cases  to  the  inferior  axillary  region.  It  is  often  reported  to  be  most 
severe  near  the  lower  margin  of  the  ribs,  and  it  is  occasionally  felt  in  the 
abdomen  and  back,  in  this  event  suggesting  the  possibility  of  a  diaphrag- 
matic involvement.  In  such  cases  the  pain  is  enhanced  by  pressure 
over  the  insertion  of  the  chaphragm  in  the  region  of  the  ninth  and  tenth 
ribs.  Fever,  if  present  at  all,  is  usually  moderate.  It  may  be  of  but 
a  few  days'  duration,  or  in  inchvidual  cases  persist  for  many  weeks. 
In  acute  pleurisy  cough  is  usually  a  symptom  of  minor  importance. 
Expectoration  is  scanty,  and  consists  largely  of  viscid  mucus  which  now 
and  then  is  streaked  with  blood.  Dj^spnea  may  be  a  conspicuous  feature 
of  cases  having  an  acute  onset.  The  stabbing  pain  in  the  side  often 
imparts  a  characteristic  restrained  and  interrupted  type  of  respiration. 
While  these  initial  manifestations  of  acute  pleurisy  are  extremely 
suggestive  of  the  condition,  they  are  occasionally  simulated  by  the 
early  symptoms  of  pneumonia,  while  effusions  of  large  size  may  exist 
without  the  slightest  subjective  disturbance.  I  have  found  with  great 
frequency  small  and  moderate  effusions  among  pulmonary  invalids  in 
the  absence  of  all  rational  symptoms.  Recognition  of  the  concUtion 
has  been  afforded  in  the  course  of  routine  physical  examinations,  and 
no  suggestion  conveyed  by  fever,  dyspnea,  pain,  cough,  nor  bj'' 
such  prodromal  symptoms  as  malaise,  loss  of  appetite,  or  emaciation. 
Without  detailed  exploration  of  the  chest  all  so-called  latent  pleurisies 
must  escape  detection.  That  pleurisy  with  effusion  is  much  more 
frequent  than  is  generally  supposed  is  explained  almost  entirely  by 
the  fact  that  it  is  overlooked  in  many  instances.  Provided  an  effort 
is  made  to  conduct  a  thorough  chest  examination,  it  is  difficult  to  con- 
ceive how  even  a  moderate  effusion  can  remain  unrecognized.  When 
such  is  the  case,  this  must  be  regarded  as  due  to  faulty  and  superficial 
methods  of  physical  exploration. 

Upon  inspection  there  may  be  noted  in  some  cases  a  diminished 
respiratory  excursion  upon  the  affected  side,  the  degree  of  immobility 
var3^ing  in  accordance  with  the  amount  of  pleural  exudation.  Oblitera- 
tion of  the  intercostal  spaces  sometimes  takes  place,  and  the  entire 
side  may  present  a  round,  bulging  appearance.  Palpation  serves 
to  confirm  the  results  of  inspection  with  reference  to  the  imilateral 
restriction  of  respiratory  movement,  and  in  addition  affords  extremely 
valuable  evidence  by  virtue  of  greatly  diminished  or  absent  vocal 
fremitus.  This  tactile  fremitus  is  almost  always  found  to  be  lessened, 
even  over  the  site  of  small  effusions.  Recourse  to  mensuration  is  of 
but  little  avail  in  determining  the  presence  of  pleural  effusions,  as 
among  consumptives  a  considerable  disparity  between  the  two  sides  of 
the  chest  is  not  infrequent.  No  con\ancing  evidence  is  thus  afforded 
as  to  the  existence  of  a  pleural  effusion,  the  signs  of  which  are  usually 
subject  to  easy  recognition  by  other  means. 

Percussion  of  the  entire  chest  is  of  the  utmost  value  in  a  search  for 
small  and  moderate  pleural  effusions  among  phthisical  patients,  although 
the  results  :iic  sdiiictiini's  obscure  on  account  of  the  extensive  pathologic 
iliaiiL;!-.  iIkii  1i:i\c  :ilrc.nl\-  taken  place  in  the  pulmonary  tissues.  Among 
(■niisuiiipti\cs  this  is  pniticularly  true  upon  percussing  the  back,  on 
account  of  the  enormous  pleural  thickening  which  is  sometimes  present 
at  one  base.     Further  difficulties  are  experienced  by  reason  of  the 


SYMPTOMATOLOGY    OF   TUBERCULOUS    PLEURISY  355 

varying  degrees  of  pulmonary  infiltration  or  areas  of  partial  consoli- 
dation. Failure  to  exhibit  typical  percussion  boundaries  may  be 
occasioned  by  the  presence  of  a  partially  consolidated  and  non-com- 
pressible lung.  The  difficulty  of  correct  percussion  interpretations 
will  at  once  be  appreciated  ujjon  consideration  of  the  modifications  of 
resonance  produced  by  such  preexisting  pathologic  change.  It  is  not 
always  easy  by  percussion  alone  to  outline  with  precision  the  border-line 
between  the  flatness  of  a  pleural  efTusion  and  the  marked  contiguous 
dulness  incident  to  compressed  lung.  In  some  instances  but  a  thin 
stratum  of  fluid  is  molded  around  the  lung,  serving  as  an  intervening 
layer  between  it  and  the  chest-wall.  The  so-called  skodaic  resonance 
so  frequently  recognized  in  the  subclavicular  region  among  non-con- 
sumptives and  resulting  from  the  relaxation  of  pulmonary  tissue  is  not 
obtainable  among  phthisical  patients,  who  exhibit  in  this  region  varying 


Fig.  94.— Typical  letter  "S 


of  consolidation  or  cavity  formation.  As  a  result  of  the  numer- 
ous pleural  adhesions  and  the  dense  fibrous  bands  traversing  the  pleural 
cavity  and  invading  the  lung,  the  former  may  be  subdivided  into  several 
circumscribed  chambers.  In  such  event  an  effusion  is  prevented  from 
assuming  the  characteristic  curve  so  common  among  non-consumptives. 
Generally  speaking,  there  is  either  complete  flatness,  or  extreme 
dulness  upon  percu.ssion  over  the  seat  of  the  effusion.  The  resonance 
has  often  been  described  as  of  a  peculiarly  wooden  or  resistant  quality. 
The  typical  letter  "S"  curve  which  marks  the  boundary  between  the 
lung  and  the  effusion  is  not  always  subject  to  verification  among  pul- 
monary invalids,  as  has  been  stated,  on  account  of  previous  morbid 
changes  in  the  lung  and  pleura.  When  present,  however,  the  lowest 
point  of  the  curve  is  invariably  near  the  spine,  and  extends  upward 
and  outward  to  the  shoulder  or  upper  axilla,  as  shown  in  Fig.  94. 
From  this  point  the  line  of  dulness  descends  obliquely  in  front  in  a 
perfectly  straight  line.     This  peculiar  configuration  of  the  upper  per- 


356  COMPLICATIONS 

cussion  boundary  is  present  only  if  the  effusion  is  of  moderate  size. 
As  this  increases  the  cur\ed  hne  of  dulness  presents  an  upward  con- 
cavity, which  is  often  extremely  difficult  of  recognition.  In  slight 
pleural  effusions  the  letter  "S"  curve  is  entirely  absent  the  line 
of  dulness  proceecUng  from  the  spine  and  dropping  suddenly  in 
the  axilla,  as  depicted  in  Fig.  95.  It  will  be.  noted  that,  as  the  fluid 
increases  from  a  small  to  a  moderate  size,  there  is  an  abrupt  and  pro- 
nounced change  in  the  upper  boundary  of  percussion  dulne.ss.  This 
phenomenon,  first  recognized  by  Weil,  and  to  which  Whitnej-  called 
attention  in  1894,  I  have  had  occasion  to  confirm  in  innumerable 
instances.  It  is  the  small  effusion  that  most  frequently  escapes  detec- 
tion, the  area  of  flatness  being  confined  to  the  lower  posterior  portion 
of  the  chest,  sometimes  extending  lateral! v  but  a  short  distance.     A 


Fig.  95. — Out  line  of  percussion  dulness  in  small  pleural  effusion.     Not 


striking  verification  of  the  letter  "  S"  curve  in  moderate  effusions  will  be 
found  by  reference  to  the  radiograph  (Fig.  73). 

Respiratory  sounds  and  even  moist  rales  are  not  uncommonly 
heard  with  distinctness  through  an  area  of  dulness.  Thus  it  is  apparent 
how  such  an  effusion  may  be  overlooked  even  by  careful  and  experienced 
examiners.  It  is  exceedingly  important  to  percuss  to  the  very  base  of 
each  lung  in  the  back,  and  to  outline  the  lower  border  of  resonance 
in  order  to  compare  accurately  the  two  sides.  The  difficulties  in  the 
way  of  correct  conclusions  in  such  comparison  may  be  increased  by  a 
unilateral  compensatory  emphysema,  which  materially  depresses  the 
lower  boundary  of  resonance. 

The  auscultatory  signs  of  especial  importance  relate  to  the  intensity 
of  the  respiratory  sovmds  anil  of  the  vocal  I'esonance.  In  early  pleurisy 
adventitious  sounds  are  often  heard  before  deviations  from  the 
normal  respiratory  murmur.  Allusion  has  been  made  to  .liirgensen's 
sign,  which  consists  of  a  peculiar  soft  rubbing  sound  simultaneous  with 
the  respiration.     This  may  be  present  in  the  beginning  of  a  distinct 


SYMPTOMATOLOGY  OF  TUBERCULOUS  PLEURISY         357 

tuberculous  pleurisy,  particularly  if  of  the  miliary  type;  In  many 
cases  dry  friction-rubs  are  recognized  in  the  axillary  regions.  The 
sounds  may  be  fine  and  grazing  in  character,  or  loud  and  creaking. 
As  a  rule,  they  are  intensified  by  pressure  with  the  stethoscope.  Occa- 
sionally the  sounds  are  somewhat  similar  to  the  crepitant  rale  previously 
described.  They  sometimes  reappear  after  the  absorption  of  an  effusion. 
Pleural  friction-rubs  are  often  jerky  or  interrupted,  and  are  heard  both 
with  inspiration  and  with  expiration. 

In  cases  of  pulmonary  tuberculosis  without  consolidation  of  lung 
near  the  site  of  the  pleural  involvement,  and  without  marked  pleural 
thickening  and  adhesions,  the  normal  respiratory  sounds  at  first  may 
not  be  appreciably  altered.  As  the  pleural  exudation  increases  the 
breath-sounds  become  enfeebled  and  markedly  distant,  and  in  large 
effusions  disappear  altogether.  Above  the  level  of  the  liquid  the  sounds 
are  sometimes  bronchovesicular  in  character,  with  a  distinct  prolonga- 
tion of  the  expiration.  Confusion  regarding  the  auscultatory  signs  may 
result  from  a  coincident  tuberculous  infiltration  in  inferior  portions  of 
the  lung.  Under  such  conditions  the  respiratory  sounds,  though  some- 
what distant  and  often  of  diminished  intensity,  may  partake  more  or 
less  of  the  characteristics  of  bronchial  or  bronchovesicular  respiration. 
Still  greater  confusion  arises  if  small  pleural  effusions  exist  in  connection 
with  localized  areas  of  lir<incliopneumonic  consolidation.  The  signs 
in  such  cases  are  occasiniiully  quite  suggestive  of  pulmonary  cavities, 
particularly  if  cUstiiu-t  Imbbliiig  rales  are  recognized.  On  the  other 
hand,  circumscribed  areas  of  bronchopneumonia  may  partially  simulate 
the  signs  of  pulmonary  cavities  or  even  of  a  pleural  effusion. 

Recently  I  have  seen  in  consultation  a  boy  of  seventeen,  the  son  of 
tuberculous  parents,  who,  in  the  midst  of  a  severe  attack  of  influenza, 
exhibited  a  small  patch  of  broncliopneumonia  at  the  right  apex.  This  was 
followed  in  a  few  days  by  several  distinct  areas  of  consolidation  at  the 
base.  During  the  early  period  of  his  illness  he  was  seen  in  consultation 
by  a  physician  of  prominence,  who  diagnosed  the  circumscribed  broncho- 
pneumonic  process  at  the  apex  as  a  tuberculous  pulmonary  cavity. 
Several  days  later  another  physician  of  exceptional  ability  recognized 
the  pneumonic  character  of  the  affection  at  the  apex  on  account  of  the 
increa.sing  area  of  consolidation,  but  announced  the  existence  of  a 
pleural  effusion.  Upon  examining  the  patient,  after  the  lapse  of  several 
days,  I  was  unable  to  recognize  any  evidence  of  pleural  effusion,  but 
found  an  unmistakable  bronchopneumonia  at  the  base.  Resolution  of 
the  consolidated  areas  speedily  followed.  Such  errors  of  diagnosis  are 
perfectly  natural  and  may  easily  fall  to  the  lot  of  the  most  experienced 
examiner. 

It  is  often  difficult  to  distinguish  povfi'ril\-  from  the  breath-sounds 
alone,  between  effusions  and  extensive  plcu  i\il  i  liickcniiigs  and  adhesions. 
In  both  instances  there  is  dulness  upon  pcicussion,  and  the  respiratory 
sounds  may  be  greatly  enfeebled  or  absent  altogether.  The  vocal  reso- 
nance and  fremitus,  which  are  diminished  or  absent  in  pleural  effusions, 
sometimes  are  also  less  intense  over  the  site  of  extensive  pleural  thicken- 
ing. The  employment  of  these  signs,  however,  is  of  great  value  in  the 
differentiation  of  pleural  effusion  and  consolidated  lung.  Generally 
speaking,  the  vocal  resonance  and  fremitus  are  accentuated  over  areas 
of  consolidation  or  compression,  and  lessened  to  a  pronounced  degree 
over  pleural  exudates. 


358  COMPLICATIONS 

Egophony,  which  has  been  described  under  Physical  Diagnosis, 
is  sometimes  heard  above  the  level  of  the  liquid.  In  tuberculous 
patients,  however,  with  pulmonary  infiltration  at  the  bases,  it  may  be 
recognized  directly  over  an  effusion.  But  little  importance  is  attached 
to  Baccelli's  sign,  which  consists  of  the  transmission  of  the  whispered 
sound  through  serous  but  not  through  purulent  exudates. 


CHAPTER  LI 
DISPLACEMENT  OF  ORGANS 

DiSPL.\CEMENT  of  organs  may  result  from  the  pushing  force  of  a 
pleural  effusion  and  from  the  traction  incident  to  excessive  fibrous 
tissue  formation.  Among  pulmonary  invalids  a  cardiac  displacement 
is  of  much  less  importance  as  an  aid  to  the  diagnosis  of  large  pleu- 
ral effusions,  than  among  non-phthisical  patients.  If  the  pulmonary 
disease  has  been  of  long  standing,  a  pronounced  traction  dislocation 
of  the  heart  often  exists  prior  to  the  development  of  an  eft'usion.  The 
characteristic  changes  in  the  position  of  the  heart  and  in  the  location 
of  the  apex  impulse  are  often  lacking,  therefore,  among  consumptives 
in  spite  of  large  effusions.  It  is  not  uncommon  to  find  the  heart  per- 
manently dislocated  to  the  left  by  adhesions  and  fibrous  tissue  prolifer- 
ation, notwithstancUng  a  moderate  left-sided  exudate,  and,  for  the  same 
reason,  displaced  to  the  right  in  the  presence  of  a  corresponding  pleural 
effusion. 

In  general,  however,  the  pressure  of  liquid  in  the  right  pleural  cavity 
often  suffices  to  tlisplace  the  liver  downward  and  the  heart  somewhat  to 
the  left.  In  left-sided  effusion  the  heart  may  be  pushed  to  the  right, 
although  the  relative  position  of  the  apex  to  base  is  not.  as  a  rule, 
altered  to  any  great  extent.  The  contraction  changes  incident  to  the  for- 
mation of  new  connective  tissue  are  sufficient  to  pull  the  heart  in  almost 
any  direction.  The  traction  is  usuall}-  the  result  of  extensive  fibrous 
tissue  proliferation  in  the  lung  as  well  as  in  the  pleura.  Upward  cUs- 
placements  from  contraction  of  mediastinal  pleiu-a  are  far  more  common 
than  is  generally  supposed.  The  most  radical  malpositions  take  place 
when  the  fibrous  tissue  proliferation  proceeds  from  chronic  pleurisies. 
The  cardiac  tUsplacement  is  then  accompanied  bv  deficient  unilateral 
expansion,  more  or  less  marked  retraction  of  the  side,  cUminished  per- 
cussion resonance,  and  impaired  respirator}-  sounds.  The  pleural  sur- 
faces are  enormously  thickened,  and  sometimes  firmly  united,  while 
fibrinous  bands  may  connect  the  pleura  with  the  pulmonary  tissue. 
Moderate  traction  displacements  are  very  often  observed  in  pulmonary 
invalids. 

I  have  been  impressed  by  the  decided  frequency  with  which  the 
a:-ray  has  shown  changes  in  the  position  of  the  heart  as  the  residt 
of  fibrosis,  notwithstanding  the  non-recognition  of  the  displacement 
upon  phy.sical  examination.  From  the  e^■idence  afforded  in  my  own 
cases  it  seems  reasonable  to  suppose  that  a  permanent  dextrocardia 
or  a  sinistrocardia  occurs  in  a  very  large  number  of  cases  of  chronic 


DISPLACEMENT    OF    ORGANS  359 

pulmonary  tuberculosis.  Contractile  changes,  like  pleural  effusions, 
may  not  only  effect  a  dislocation  of  the  heart  as  a  whole,  but  may  also 
produce  occasionally  an  alteration  in  the  relative  position  of  the  apex 
to  base.  In  cases  of  traction  displacement  to  the  left,  the  ajjex  is  fre- 
quently more  or  less  elevated,  which  is  not  the  case  in  right-sided  dis- 
locations. Contractile  processes  in  the  upper  portion  of  the  left  lung, 
with  pronounced  involvement  of  the  mediastinal  pleura,  may  be  sufficient 
to  lift  the  heart  upward  and  slightly  to  the  left.  There  may  be,  however,  a 
disproportionate  displacement  of  the  apex,  which  is  pulled  upward  toward 
the  left  axilla.  It  is  much  less  common  to  note  an  elevation  of  the  apex 
in  right-sided  displacements,  as  the  line  of  traction  is  not  exerted  upon 
the  apex  itself.  In  such  malpositions  the  heart  is  moved  more  or  less  en 
masse:  although  the  visible  and  palpable  impulse  is  sometimes  recognized 
as  far  to  the  right  as  the  nipple,  or  even  beyond  this  point.  This  appar- 
ent apex  impulse,  however,  may  be  in  reality  but  a  transmission  of  the 


Fig.  96. — Slight  cardiac  displacement  to  the  left  in  case  of  long-standing  tuberculous  involvement 


movements  of  the  right  ventricle,  which  has  become  pulled  into  direct 
contact  with  the  chest-wall. 

The  extent  of  cardiac  displacement  frequently  observed  among 
pulmonary  invalids  as  a  result  of  fibrous  tissue  change  is  shown 
in  Figs.  96  to  103.  In  eacli  instance  the  photograph  was  taken  after 
scrupulous  care  in  outlining  the  area  of  cartliac  dulness,  the  X  indicating 
the  point  of  maxinuim  cardiac  impulse. 

Fig.  97  illustrates  an  extreme  left-sided  malposition  in  a  young 
man  of  seventeen  years,  as  a  result  of  fibrosis  incident  to  the  arrest 
of  an  extensive  tuberculous  involvement.  The  condition  of  the 
patient  upon  arrival  in  Colorado,  April,  1906,  was  regarded  by 
several  physicians  including  myself  as  extremely  desperate.  There 
was  emaciation  with  marked  physical  debility,  pronounced  pallor,  an 
afternoon  temperature  of  103°  F.  or  over  daily,  frequent  distressing 
cough,  and  dyspnea.     The  pulse  was  invariably  rapid,  rarely  receding 


360 


COMPLICATIONS 


under  120  in  the  morning.  Examination  of  the  chest  disclosed  exten- 
sive active  infection  of  the  entire  left  lung,  which  was  consolidated  to  a 
moderate  extent.  Coarse  bubbling  rales  were  heard  from  apex  to  l«ise. 
Moisture  was  also  detected  in  the  rijiht  luii-  from  the  apex  to  the  clavicle 
and  to  the  middle  third  of  the  interscapuhii-  space.  At  the  expiration  of 
eight  months  the  patient  had  gained  sixty  iiounds  in  weight,  exhibiting 
an  entire  disappearance  of  fever,  cough,  and  expectoration.  During 
the  past  year  further  improvement  has  been  continuously  maintained. 
There  are  no  longer  phj^sical  signs  in  the  right  lung,  and  upon  the  left 
side  there  is  a  marked  lessening  of  the  activity  of  the  process,  with  ex- 
tensive fibrosis.  There  is  no  moisture  in  the  left  front,  and  but  occa- 
sional fine  clicks  in  the  back.  Skiagraphic  confirmation  of  the  percussion 
cardiac  boundaries  is  shown  in  Fig.  63. 

Fig.  98  illustrates  the  possibility  of  extreme  lateral  displacement 
attencling  a  tuberculous  pleurisy  with  pulmonary  infection.  The 
patient,  twenty-nine  years  old,  came  to  Colorado  January  6,  1900,  eight 


years  after  the  development  of  a  tuberculous  invasion.  There  were 
great  loss  of  weight,  physical  debility,  and  dyspnea.  In  addition  to 
tuberculous  involvement  of  each  lung  a  left-sided  pleural  effusion  was 
recognized.  Upon  aspiration  there  were  withdrawn  eight  ounces  of  dark 
blood,  which  immediately  coagulated.  Several  subsequent  aspirations 
were  of  similar  character.  Extensive  connective-tissue  change  emana- 
ting from  the  pleiu-a  and  involving  the  lung  has  resulted  in  the  cUsplace- 
ment  shown  by  physical  examination  and  confirmed  by  the  skiagraph 
as  shown  in  Fig.  66.  The  patient  has  completely  recovered  from  tiie 
tuberculous  process.  Unilateral  retraction  of  the  chest  is  very  apparent. 
The  next  case  presents  features  in  striking  contrast  to  the  pre- 
ceding, A  young  man  twenty-six  years  old,  a  patient  of  Dr.  Hooker, 
of  Springfield,  Mass.,  came  under  my  ob.servation  February  11.  1899. 
His  illness  developed  in  November,  1898,  at  which  time  he  experienced 
a  series  of  very  severe  hemorrhages.     There  was  moderate  tuberculous 


DISPLACEMENT    OF    ORGANS 


361 


infection  of  the  right  lung.  Shortly  after  arrival,  however,  a  pleural  effu- 
sion developed  upon  the  right  side,  which  was  aspirated  several  times, 
and  a  large  quantity  of  serous  fluid  withdrawn.  The  patient  made  an 
uninterrupted  recovery  and  has  enjoyed  a  period  of  active  usefulness. 

While  there  are  no  physical  or  sul)jecti\-e  evidences  of  a  remaining 
active  infection,   a   marked  unilateral    deformity  has   taken   place,  as 


Fig.  99.— Well- 


shown  in  Fig.  99.  It  is  interesting  to  note,  however,  that  despite  the 
extensive  contraction  change  the  position  of  the  heart  remains  prac- 
tically  normal,   as  shown  in   Fig.  100.     Another  noteworthy  feature 


is  the  swinging  of  the  sternum  towartl  the  affected  side,  as  indicated  by 
the  straight  line  drawn  directly  over  the  center  of  the  sternum. 

Fig.  101  represents  the  position  of  the  heart  as  determined  by 
percussion  in  a  woman  of  twenty-five  suffering  from  extensive  tuber- 
culous infection  of  both  lungs  of  ten  years'  duration.  At  the  time  she 
came  under  my  care,  December  12,  1898,  the  condition  was  extremely 


362 


COMPLICATIONS 


unfavorable.  There  were  daily  temperature  elevations,  malnutrition, 
and  active  tuberculous  involvement  throughout  the  right  lung,  with 
slight  infection  of  the  left.  An  apparent  arrest  of  the  tuberculous  proc- 
ess in  the  right  lung  was  eventually  secured,  the  fibroid  changes  becoming 


Fig.   IU2.— Displa 

nt  with  extensiv( 

gilt   lung.     (Compar 


the    heart 
tuberculous  involi 
with  radiograph. 


the    heart    3 

changes  in  t  _  _ 

standSngpuhnonar>-  tuberculosis.      (Compare 
with  radiograph.  Fig.  62.) 

extremely  marked.  Sub.sequently  there  resulted  a  renewed  activity  of 
the  infection.  The  e.xtent  of  the  displacement  as  determined  upon 
percussion  is  verified  Ijy  the  .r-ray  pictui-e  (Fig.  62).  The  skiagraph 
not  onlj-  illustrates  the  marked  traction  exerted  upon  the  heart  by  the 


Fig.    103.— UhLstrat 


•ith  pul- 


fibroid  proliferation,  but  also  the  extensive  pathologic  change  throughout 
the  entire  chest. 

In  cases  similar  to  those  just  cited,  it  is  manifest  that  no  significance 
can  be  attached  to  the  cardiac  displacements  as  an  aid  to  diagnosis  of 
pleural  effusions. 


DIAGNOSIS    AND    PROGNOSIS    OF    PLEURAL    EFFUSION 


CHAPTER  LII 

DIAGNOSIS  AND  PROGNOSIS  OF  PLEURAL   EFFUSION 
IN  PULMONARY  INVALIDS 

Great  variations  are  observed  in  the  course  of  pleurisies  developing 
among  pulmonary  invalids.  The  fever  which  is  often  present  in  the 
beginning  may  not  continue  longer  than  a  week  or  ten  days,  but  in 
some  cases  the  temperature  maj^  remain  elevated  for  prolonged  periods, 
and  be  associated  with  other  symptoms  of  constitutional  disturbance, 
more  or  less  profound,  according  to  the  bacterial  nature  of  the 
effusion.  As  a  rule,  the  manifestations  of  cardiac  and  respiratory 
embarrassment  correspond  approximatel}'  to  the  size  of  the  exudate. 
It  is  surprising,  however,  to  note  occasionally  considerable  dyspnea  with 
temperature  elevation  and  a  rapid  pulse  in  comparatively  small  effusions. 
Comment  has  been  made  upon  the  fact  that  astonishingly  large  pleural 
exudates  may  exist  without  the  slightest  symptoms  of  their  presence. 
The  effusion  may  remain  of  small  or  moderate  size  for  a  short  period 
and  cUsappear,  or  it  may  persist  indefinitely  without  perceptible  increase 
in  volume. 

While  the  effusion  in  many  cases  is  absorbed  with  varying  degrees 
of  rapicUty  it  sometimes  is  found  to  increase  progressively  in  size, 
the  volume  of  contained  liquid  being  so  great  as  to  demand  removal. 
In  such  cases,  particularly  among  pulmonary  iinnlids,  there  is  con- 
siderable likelihood  of  reaccumulation,  even  if  tlie  ertusicm  li(>  seimis  in 
character.  I  have  never  seen  sudden  death  from  jiulnioiiaiy  cmliolisni 
in  connection  with  pleural  effusions,  although  instances  of  this  have 
been  reported,  especially  when  the  heart  iias  Iteen  greatly  dislocated. 
In  one  instance,  however,  a  sudden  fatal  termination  took  place  twelve 
hours  after  the  withdrawal  of  a  large  effusion. 

From  what  has  been  stated  with  reference  to  the  physical  signs, 
it  is  conceivable  that  errors  of  diagnosis  should  occur,  only  in 
exceptional  cases,  provided  there  be  condncted  ;in  intolliaciit  chest 
examination.  Non-recognition  of  pleuritic  cimi|i|ic:irK)iis  is  dcciMdned 
in  the  majority  of  instances,  not  because  of  ;uiy  ;il>sencc  of  re^idily 
available  data  for  this  purpose,  but  through  failure  to  apply  the  estab- 
lished principles  of  diagnosis  to  the  evidence  presented.  In  this 
connection  it  may  be  stated  that  the  frequent  unfortunate  results  of 
treatment  are  sometimes  due  not  so  much  to  the  lack  of  adequate 
therapeutic  measures,  as  to  the  misconception  of  their  rational  scope  in 
individual  instances.  It  may  be  stated  parenthetically  that,  unlike 
many  diseases  of  the  lungs,  the  primary  ob.stacles  to  success  in  the 
management  of  pleural  complications  in  pulmonary  tuberculosis  may 
not  be  ascribed  invarialily  to  delayed  diagnosis.  It  is  a  humiliating 
reproach  to  state  thai  iidt  inl're<|uently  the  interests  of  the  patient 
would  be  better  suliseixcd  if  tlie  cciiidition  remained  unrecognized. 
The  justice  of  this  i-eHectiou  upon  tlie  medical  and  surgical  manage- 
ment, in  some  cases,  will  be  later  explained.  While  early  diagnosis 
must  be  encouraged  through  detailed  examinations  of  the  chest, 
the  essential  considerations  relate  to  a  correct  interpretation  of  the 
prognostic  significance  of  the  effusion  in  individual  cases,  and  an 
intelligent  appreciation   of  the   rationale  of  remedial   measures.     Let 


364  COMPLICATIOXS 

it  be  emphasized  that  the  existence  of  pulmonary  tuberculosis 
very  materially  modifies  the  consiileration  of  those  surgical  methods 
which  maj-  be  styled  operations  of  cvpediency.  At  the  same  time  the 
consumptive,  no  matter  how  hopeless  his  condition,  is  entitled,  by 
\'irtue  of  everj^  instinct  of  humanity-  to  the  fullest  measure  of  surgical 
aid  in  conchtions  involving  so-called  operations  of  necessiti/.  My  con- 
clusions are  derived  from  the  errors  as  well  as  the  successes  incident 
to  personal  experience.  More  of  real  benefit  sometimes  accrues  from 
an  opportunity  to  witness  the  deplorable  results  of  mistaken  judgment 
than  from  the  elated  observation  of  a  successful  issue  following  a  fortu- 
nate choice  of  procedure. 

In  support  of  views  to  be  presented,  a  few  illustrative  cases  will  be 
presently  introduced. 

The  diagnosis  of  pleural  effusion  is  too  frequently  dependent  upon 
an  employment  of  the  aspirating  neeiUe.  A  provisional  diagnosis 
having  been  established  by  the  physical  signs,  verification  is  commonly 
attempted  through  recourse  to  exploratory  puncture.  This  procedure, 
though  often  affording  positive  results,  does  not  invariably  yield  infor- 
mation of  a  reliable  nature,  owing  to  errors  of  technic  in  inexperienced 
hands.  I  have  known  numerous  instances  of  moderate  effusion,  particu- 
larly of  circumscrilsed  empyema,  to  remain  unconfirmed  by  aspiration. 

The  tendency  to  withdraw  the  pleural  exudate  is  especially  strong 
among  young  practitioners.  So  far  as  the  diagnosis  perse  is  concerned,  the 
use  of  the  aspirating  needle  by  trained  clinicians  affords  a  most  trust- 
worthy and  reliable  aid  to  accuracy  of  conclusions.  In  the  majority  of 
cases,  however,  a  rigid  and  painstaking  examination  of  the  entire  chest 
is  sufficient  to  enable  a  skilful  clinician  to  arrive  at  an  accurate  diagnosis. 
Attention  has  been  called,  however,  to  the  peculiar  cUfficuIties  sometimes 
involved  in  the  physical  examination  of  pulmonary  invalids  with  compli- 
cating pleural  effusions.  For  years  it  has  been  customary  for  writers 
to  emphasize  the  variation  in  the  level  of  percussion  dulness  in  pleural 
effusions  upon  change  in  the  position  of  the  patient.  While  I  am  not 
prepared  to  deny  with  positiveness  that  some  slight  modification  of 
the  level  of  the  effusion  ma}'  be  detected  in  exceptional  cases  when  the 
patient  assumes  a  different  position,  my  own  experience  is  to  the  effect 
that  such  mobility  of  percussion  outlines,  as  a  rule,  is  exceedingly  slight, 
and  rarely  constitutes  a  factor  of  especial  diagnostic  value.  It  appears 
unwise  to  lay  stress  upon  a  technical  point  which  is  often  incapable  of 
detection  even  by  expert  examiners,  for  confusion  and  discouragement 
must  unavoidably  result  in  the  minds  of  students  who  attempt  to  recog- 
nize the  existence  of  so  slight  and  inconstant  a  variation  of  percussion 
boundaries.  As  a  matter  of  fact,  the  only  practical  value  attaching 
to  change  in  the  level  of  the  effusion  simultaneously  with  differing 
postures,  is  found  in  cases  of  pneumopyothorax,  in  which  there  is  not 
only  liquid,  but  air,  in  the  pleural  cavity.  In  these  cases  the  change 
is  most  pronoimced  and  should  be  capable  of  recognition  by  the  \-eriest 
amateur  in  physical  examinations.  There  are  other  interesting  features 
in  connection  with  the  level  of  the  liquid  in  the  latter  affection,  which 
will  be  discussed  in  their  appropriate  place. 

The  .subjective  symptoms  in  pleural  effusions,  though  decidedly 
unreliable  as  diagnostic  features,  are  nevertheless  possessed  in  some 
instances  of  more  or  less  clinical  importance.  The  gradual  develop- 
ment, the  moderate  fever,  slight  cough,  and  scanty,  mucoid  expecto- 


DIAGNOSIS    AND    PROGNOSIS    OF    PLEURAL    EFFUSION  365 

ration  are  distinctly  suggestive  of  pleural  effusion  in  contradis- 
tinction to  the  sudden  onset,  the  chill,  abrupt  elevation  of  tempera- 
ture, distressing  cough,  and  tenacious  or  blood-streaked  expectoration 
characteristic  of  pneumonia.  The  dyspnea  is  almost  always  accentuated 
to  a  greater  degree  in  pneumonia  than  in  pleural  effusion.  I  have 
been  in  the  habit  of  attaching  considerable  diagnostic  significance  to 
the  presence  of  herpes  labialis  in  pneumonia.  Although  by  no  means 
pathognomonic  of  this  condition,  it  is,  at  least,  quite  unusual  in  acute 
pleurisies.  The  existence  of  leukocytosis  in  doubtful  cases  is,  of  course, 
suggestive  of  pneumonia. 

The  prognosis  of  pleural  effusions  in  consumptives  depends  pri- 
marily upon  the  extent  and  degree  of  activity  of  the  tuberculous  process, 
and  conforms  to  a  great  extent  to  the  principles  of  prognosis  enumerated 
with  reference  to  the  pulmonary  infection.  In  addition  to  this  the 
outlook  for  the  patient  depends  largely  upon  the  caiise  and  nature  of 
the  pleurisy  and  the  character  of  the  therapeutic  management.  Many 
effusions  may  remain  unresolved  for  years,  and  yet  not  seriously  affect 
the  welfare  of  the  invalid.  Other  pleurisies,  by  virtue  of  their  absorp- 
tion, not  infrequently  produce  a  disastrous  influence  upon  the  general 
condition.  Among  pulmonary  invalids  I  have  noted  that  the  develop- 
ment of  moderate  pleural  effusions  has  sometimes  been  followed  by 
most  gratifying  results,  which  had  previously  been  impossible  of  attain- 
ment. The  foregoing  prelirninary  considerations  will  be  more  fully 
elaborated  in  connection  with  treatment. 

Serous  effusions  are  the  only  ones  likely  to  IxHonio  al )sorbed  or  not 
to  reaccumulate  after  aspiration.  Exudates  wlii(  h  niaihially  assume 
a  greater  cloudiness  with  increasing  number  of  leukocytes  often  assume 
eventually  the  characteristics  of  a  purulent  effusion,  and  become  subject 
to  the  principles  of  prognosis  and  treatment  applical^le  to  empyema. 

While  serous  effusions  are  much  more  benign  than  those  which  are 
purulent,  the  latter  variety  in  many  phthisical  patients  apparently 
exercises  no  more  detrimental  effect  than  the  distinctly  serous  exu- 
dates. This  statement  applies  exclusively  to  sterile  effusions  unattended 
by  septic  absorption.  The  prognosis  varies  materially,  according  to 
the  specific  microorganism  present  in  the  exutlate,  the  degree  of  consti- 
tutional disturbance,  and  the  nature  of  subsequent  treatment. 

The  observations  of  Courmont  concerning  the  seroprognosis  of  tuber- 
culous pleurisies  are  extremely  intei'esting.  He  has  shown  that  the 
degree  of  agglutinating  power  of  the  blood  in  typhoid  fever  is  com- 
paratively small  in  the  presence  of  the  more  virulent  infections,  and 
large  in  proportion  to  the  resistance  of  the  individual.  Griffon,  a  few 
years  later,  demonstrated  that  the  agglutinating  power  of  the  blood  in 
pneumonia  is  greatest  at  the  time  of  recovery,  and  almost  absent  in 
hopeless  cases.  Courmont  and  Arloing  have  reported  that  the  maximum 
agglutination  of  the  blood  is  greater,  as  a  rule,  in  benign  cases  of  pulmo- 
nary tuberculosis,  and  that  it  is  slight  in  the  desperate  forms.  Courmont 
has  devoted  a  vast  amount  of  study  to  the  agglutinating  power  of  the 
blood-serum  and  of  the  serous  effu.sions  in  tuberculous  and  non-tuber- 
culous pleurisies.  He  found  that  the  non-tuberculous  exudates  do  not 
agglutinate  the  bacillus  of  Koch,  and  that  the  greater  part  of  the  tuber- 
culous fluids  agglutinate  tubercle  bacilli  in  the  proportion  of  one  to  five 
up  to  one  to  twenty.  His  more  recent  conclusions  are  to  the  effect  that 
the  prognosis  of  tuberculous  exudates  is  favorable  in  proportion  to  a 


366  COMPLICATIONS 

high  agglutinating  power  of  the  effusion,  and  becomes  more  grave  with 
a  diminution  or  absence  of  the  reaction.  The  maximum  agghitination 
took  place  as  the  patients  proceedetl  toward  recovery,  while  a  chminution 
was  found  to  occur  as  the  conchtion  became  more  desperate.  His  con- 
clusions are  as  follows: 

"  1.  The  mortality  is  about  25  per  cent,  in  cases  the  pleural  effusion 
of  which  has  agglutinating  power,  and  75  per  cent.,  on  the  contrary,  in 
those  in  which  the  fluid  has  no  agglutinating  power. 

"2.  Among  patients  with  an  agglutinating  effusion  the  number  of 
recoveries  is  large  in  proportion  as  the  agglutination  is  high. 

"3.  One  can  observe  the  agglutinating  power  of  the  effusion  increase 
in  proportion  as  the  case  progresses  to  recovery,  and,  on  the  contrary, 
chminish  in  those  patients  in  whom  the  termination  is  near." 


CHAPTER   LIU 

TREATMENT  OF  SEROUS  EFFUSION 

To  avoid  confusion  it  is  well  to  consider  separately  the  management 
of  serous  and  purulent  effusions  among  phthisical  patients.  The  treat- 
ment of  serous  exudates  must  necessarily  vary  in  accordance  with  the 
strength  and  vigor  of  the  invalid,  the  chronicity  of  the  effusion,  the 
degree  of  pain,  the  constitutional  disturbance,  and  the  extent  of  respira- 
tory and  cardiac  embarrassment.  There  is  no  arbitrary  system  of  man- 
agement which  is  rationally  applicable  to  all  individuals.  Each  case 
should  be  regarded  as  a  law  unto  itself,  the  therapeutic  inchcations 
being  determined  upon  the  merits  of  the  patient,  as  well  as  the  effusion. 
Irrespective  of  considerations  pertaining  to  the  exudate,  the  course  of 
procedure  must  be  mocUfied  in  accordance  with  the  extent  and  activity 
of  tuberculous  change  and  the  apparent  effect  of  the  effusion  upon  the 
general  condition.  The  primary  consideration  relates  to  a  determi- 
nation as  to  whether  or  not  the  pleural  involvement  is  doing  actual 
harm  by  virtue  of  the  pain,  chscomfort,  fever,  dyspnea,  and  cardiac 
embarrassment,  or  producing,  for  the  time  lieing,  relief  of  cough,  severe 
pleuritic  pain,  or  tendency  to  hemorrhage.  It  is  at  once  obvious  that 
upon  a  correct  interpretation  of  its  influence  will  depend  an  intelligent 
conception  of  its  management.  In  some  cases  it  will  be  found  best  not 
to  disturb  the  effusion,  while  in  others  the  indications  for  energetic  in- 
terference become  highly  imperative.  The  precise  manner  of  procedure 
appropriate  for  patients  who  are  little  reduced  physically  is  scarcely 
appropriate  for  those  with  a  similar  effusion  but  much  prostrated  from 
prolonged  disease,  and  offering  but  vevy  slight  prospects  for  reco\'ery 
from  the  pulmonary  condition.  Among  many  individuals  the  size  and 
effect  of  the  effusion  are  not  sufficient  to  demand  operative  interference 
in  order  to  save  life.  Whenever  the  local  condition  is  such  as  to  demand 
operations  of  necessiti/,  even  an  apparently  hopeless  general  condition 
should  in  nowise  preclude  the  effort  to  render  surgical  aid.  It  is  needless 
to  state  that  the  condition  of  the  patient  necessarily  modifies  in  some 
instances  not  only  the  choice  of  surgical  procedure,  but  also  the  nature 


TREATMENT  OF  SEROUS  EFFUSION  367 

of  the  medical  treatment.  Active  depletion,  venesection,  and  catharsis, 
though  of  undoubted  value  in  selected  cases,  nevertheless  may  result 
in  incalculable  injury  through  their  indiscriminate  use. 

Sometimes  relief  of  pain  is  urgently  indicated.  In  mUd  cases  this 
may  be  accomplished  by  counterirritation,  blisters,  and  warm  applica- 
tions. Hot  flaxseed  poultices  are  occasionally  productive  of  great 
comfort.  If  but  little  relief  is  afforded  by  such  means,  I  have 
been  in  the  habit  of  resorting  to  dry  cupping  of  the  chest  over  the 
seat  of  pain,  and  the  results,  as  a  rule,  have  been  highly  satisfactory. 
Fixation  of  the  ribs  by  tight  strapping  with  adhesive  plaster  often 
gives  immediate  relief.  It  is  desirable,  however,  that  the  overlapping 
plaster  shoidd  be  drawn  very  tightly,  each  strap  being  not  less  than 
two  inches  wide.  When  the  pain  does  not  yield  to  such  measures, 
recourse  may  be  taken  to  the  administration  of  one  or  two  doses  of 
morphin  hypodermatically  luitil  the  early  suffering  is  in  part  controlled. 
I  have  observed  several  obstinate  cases  in  which  large  hypodermatic 
doses  of  morphin  repeated  at  short  intervals  have  been  insufficient  to 
afford  relief.  In  a  few  instances  I  have  not  hesitated  to  resort  to  free 
general  venesection,  which  procedure  has  been  followed  by  the  imme- 
diate disappearance  of  pain. 

In  general  a  brisk  calomel  purge  should  be  administered  early, 
followed  by  the  daily  use  of  saline  cathartics,  large  watery  evacuations 
tending  to  promote  reabsorption  of  the  exudate.  The  salicylates  have 
been  found  to  induce  moderate  i:>erspiration  and  to  aid  indirectly  in  the 
absorptive  process.  In  the  n(in-;iciite  cases,  and  particularly  in  the 
absence  of  fever,  potassium  idilid  is,  perhaps,  of  some  use  in  promoting 
the  disappearance  of  the  effusimi.  Siiiuiltaneously  with  efforts  to  hasten 
absorption  the  patients  slioiild  be  iiistrurtcd  to  ingest  but  small  quan- 
tities of  liquid.  It  is  iiitcicsf  in^  id  note  iluit  among  pulmonary  invalids 
marked  general  impi(i\cnicnt  may  occasionally  take  place  as  a  result 
of  the  development  of  small  effusions.  Several  years  before  Murphy 
proclaimed  his  treatment  of  tuberculosis  by  the  introduction  of  nitrogen 
gas  into  the  pleural  ca\dty,  it  had  been  observed  that  the  compression 
of  lung  by  pleural  effusions  sometimes  produced  a  salutary  effect  upon 
the  immediate  course  of  pulmonary  tulierculosis.  There  were  occa- 
sionally manifested  a  diminution  of  fever,  improvement  in  cough,  marked 
lessening  of  the  expectoration,  absence  of  previous  pleuritic  pains,  and 
a  material  gain  in  weight.  The  prompt  removal  of  the  effusion  by 
aspiration  was  followed  in  several  instances  by  an  aggravation  of  annoy- 
ing symptoms,  which  were  previously  held  in  abeyance.  Such  pro- 
cedure was  frequently  the  precursor  of  an  exacerbation  of  temperature, 
increase  of  cough  and  expectoration,  loss  of  weight,  and  an  apparent 
renewed  activity  of  the  tuberculous  process.  This  would  suggest  the 
positive  benefit  sometimes  to  be  derived  from  the  intrapleural  com- 
pression of  lung  for  varying  periods.  It  should  be  remembered,  how- 
ever, that  a  favorable  influence  does  not  always  obtain,  even  in  pleural 
effusions;  that  these  benefits  are  usually  but  temporary,  and  that 
no  artificial  compression,  either  by  gas  or  external  contrivances,  save 
in  exceptional  instances,  and  to  fulfil  special  indications,  is  to  be 
commended.  In  other  words,  it  is  not  the  treatment  of  the  tuber- 
culous lung  per  se,  nor  the  tuberculous  effusion  alone,  that  should 
represent  the  effort  of  the  medical  adviser,  but  rather  the  manage- 
ment  of   the   tuberculous    individual.      Laudable   as   have    been    the 


368  COIIPLICATIOXS 

attempts  to  secure  a  favomlilc  cffcrt  upon  the  tuberculous  process  by 
direct  mechanical  compressinn,  ii  iiuist  be  stated  that  the  clinical 
results  have  not  been  particuLnly  .liiaiihing.  It  is  no  detraction  from 
the  genius  of  Murphy  to  alkule  to  the  frequent  impracticability  of  his 
method,  and  to  discourage  its  adoption  for  general  purposes.  It 
remains,  however,  for  the  practitioner  to  take  cognizance  of  the  prac- 
tical truth  emphasized  by  his  work,  to  the  effect  that  in  some  cases  an 
idiopathic  compression  from  serous  effusion  may  be,  for  the  time  being, 
of  distinct  value.  To  say  the  least,  efforts  to  secure  its  immediate 
removal  by  absorption  or  aspiration  are  not  invariably  demanded  among 
pulmonary  invalids.  The  practical  lesson  relates  to  whether  or  not 
there  exist  special  indications  for  its  removal.  At  this  juncture  the 
advisability  of  exploratory  puncture  or  as])iration  must  be  considered. 

Indications  and  Contraindications  for  Aspiration. — A  very 
decided  difference  of  opinion  exists  as  to  the  indications  for  and  against 
the  aspiration  of  pleural  effusions  in  pulmonary  phthiiis.  The  majority 
of  clinicians  are  prone  to  advocate  the  withdrawal  of  the  exudate 
as  soon  as  the  diagnosis  is  established.  Their  attitude  is  based  upon 
the  assumption  that  the  longer  the  fluid  is  permitted  to  remain  in  the 
pleural  cavity,  the  greater  the  likelihood  of  firm  adhesive  inflammation, 
permanent  lung  compression,  bronchiectasis,  chronic  interstitial  pneu- 
monia, and  deformities  of  the  chest.  Their  position  is  apparently 
justified  by  the  self-evident  truth  that,  (jcneralli/  speaking,  no  indi\-idual 
can  be  expected  to  derive  benefit  from  a  pleural  effusion,  and  that  there 
is  no  justifiable  excuse  for  withholding  its  removal  until  the  advent  of 
dangerous  symptoms.  They  assume,  further,  that  compression  of  lung 
from  any  cause  is  not  good  for  the  patient  or  the  lung.  It  must  be 
admitted  that  these  postulatory  statements  are  absolutely  correct  as 
far  as  they  apply  to  non-consumptives,  and  even  to  the  majority  of 
phthisical  patients  suffering  from  acute  pleural  effusion.  From  the 
observation  of  many  ra-^i-s  of  plcui-.'i!  cffusicin  :unong  pulmonary  invalids, 
both  with  and  withmil  aspiiatimi.  1  haxc  Uccii  constrained  for  some 
years  to  take  exceptimi  \n  tliis  as  an  iiir.irliihl,'  procedure.  Consump- 
tives should  scarcely  i)e  embraced  in  the  same  category  with  non-tuber- 
culous cases  as  far  as  pertains  to  the  indications  for  aspiration.  In  the 
pleural  effusions  of  pulmonary  invalids  a  new  element  is  introduced, 
which  does  not  appear  among  the  so-called  idiopathic  cases.  The  indi- 
cations for  the  removal  of  the  effusion  are  subject  to  considerable  vari- 
ation, according  to  the  acuteness  or  chronicity  of  the  exudate,  the  likeli- 
hood of  its  reaccumulation,  and  the  general  condition.  Tuberculous 
cases  should  not  be  aspirated  save  in  the  presence  of  certain  special 
indications,  the  mere  existence  of  a  moderate  pleural  effusion  in  a 
consumptive  affording  insufficient  wariant  for  its  immediate  removal. 
If  the  effusion  he  sufficient  in  extent  to  occasion  cardiac  or  respiratory 
embarrassment,  the  demand  for  its  witlidiawal  is  peremptory  and  brooks 
of  no  delay.  Even  the  character  of  the  effusion  constitutes  no  ahso- 
lutclii  reliable  guide  as  to  the  method  of  procedure  in  consimiptives. 
The  principle  of  surgery  that  pus  wherever  found  should  be  evacuated 
does  not  always  hold  true  with  icfcifiicc  to  ]ihniral  effusions  in  phthisi- 
cal patients.  In  such  cases  tlic  coiisidciation  is  not  so  much  the  char- 
acter of  the  effusion,  as  its  effect.  I'liis  pliasc  of  the  subject  will  be  dis- 
cussed in  connection  with  empyema. 

In  order  to  afford  greater  clearness,  it  is  well  to  review  briefly  the 


TREATMENT  OF  SEROUS  EFFUSION  369 

manner  in  which  spontaneous  absorption  is  supposed  to  take  place  and 
the  arguments  that  have  been  advanced  upon  pathologic  grounds  for 
its  early  aspiration. 

Forchheimer  has  recently  called  attention  to  the  methods  by  which 
serous  effusions  are  removed  by  nature.  Absorption  by  the  veins  is 
shown  to  be  enhanced  up  to  a  certain  point  by  the  increased  intra- 
pleural pressure  occasioned  by  the  effusion,  but  later  to  be  much 
diminished  or  entirely  absent  on  account  of  the  compression  of  the  veins 
themselves.  West,  as  quoted  by  Forchheimer,  takes  the  ground  that 
absorption  occurs  much  more  through  the  lymphatics  than  through  the 
veins.  He  likens  the  pleural  cavity  unto  a  lymph-space  possessing  a 
lining  of  endothelial  cells,  the  interlying  stomata  forming  the  openings 
of  lymph  capillaries  which  finally  lead  into  the  thoracic  duct.  In  the 
presence  of  a  large  effusion  absorption  tlii(Jiii;h  the  1\  iii])liati('s  is  sup- 
posed to  cease  on  account  of  the  greatly  iliminislicd  icspiiatoiy  act  and 
the  consequent  inefficient  "lymph-pump."  Forchheimer  regards  the 
compression  of  the  lung  by  the  pleural  effusion  as  an  essential  factor 
in  the  diminished  alxsorption,  because  of  the  simultaneous  compression 
of  the  stomata  and  the  lymph-vessels,  as  well  as  the  veins.  He  thus 
explains  the  absence  of  absorption  in  less  extensive  effusions  because 
of  a  similar  effect  upon  the  smaller  portion  of  lung.  It  would  seem 
rather  difficult  to  explain  upon  this  hypothesis  the  rapid  absorption 
that  sometimes  takes  place  even  in  large  effusions  following  the  removal 
of  a  comparatively  small  portion  of  the  exudate.  Irrespective  of  the 
pathologic  cause,  it  is  known,  however,  that  the  larger  the  effusion,  the 
less  likelihood  of  absorption.  Doerfler's  work  is  also  referred  to  in  con- 
nection with  pleural  exudates  of  tulierculous  nature.  It  is  shown  that 
with  the  prompt  removal  of  the  fluid  by  aspiration  a  preexisting  anemia, 
due  to  the  compression,  is  followed  by  an  artificial  hyperemia.  This 
hyperemia  is  daimetl  to  be  more  or  less  permanent  by  reason  of  vaso- 
motor paralysis,  and  is  apparently  analogous  in  principle  to  the  Bier 
treatment  of  inflammations.  If  this  be  true,  an  increased  leukocytosis 
is  inevitable,  with  a  resulting  increased  formation  of  connective  tissue, 
which  is  supposed  to  inhibit  to  some  extent  the  further  progress  and 
development  of  the  tubercle.  The  above  is  the  argument  in  favor  of 
the  performance  of  early  aspiration  in  pleural  effusions,  and  may  be 
accepted  as  applicable  in  part  to  the  non-f ubcrcuhius  as  well  as  the 
tuberculous  varieties.  In  view  of  these  reu,^i  ms.  i  c  luci  her  with  the  greater 
likelihood  of  permanent  lung  compression  ami  the  danger  of  sudden 
death,  it  would  seem  that  there  could  be  no  valid  ground  to  dispute  the 
wisdom  of  prompt  aspiration  in  all  cases  of  pleural  effusion  provided 
there  is  not  coexistent  such  pulmonary  involvement  as  to  modify  con- 
clusions in  individual  instances.  In  some  cases  the  condition  of  the 
patient  is  of  more  essential  importance  than  the  existence  of  a  moderate 
exudate  producing  no  subjective  symptoms.  The  logic  of  clinical 
facts  regarding  the  welfare  of  the  phthisical  invalid  will  be  found 
more  satisfying  in  the  treatment  of  pleural  effusions  among  con- 
sumptives than  adherence  to  formulated  tlieories.  There  can  be  no 
doubt  as  to  the  wisdom  of  aspiration  in  cases  of  acute  effusion  asso- 
ciated with  fever,  dyspnea,  increased  cough,  or  with  the  development 
of  symptoms  dangerous  to  life.  The  majority  of  serous  effusions  among 
consumptives,  however,  are  of  insidious  origin,  exhibiting  a  definite 
chronicity  in  their  course,  a  tendency  to  reaccumulate  after  aspiration 

24 


370  COMPLICATIONS 

and  an  inability  to  attain  large  proportions  on  account  of  antecedent 
pulmonary  and  pleuritic  change. 

In  chronic  effusions  it  is  not  necessary  to  resort  invariably  to  aspii-a- 
tion  in  the  absence  of  fever  and  dyspnea,  or  of  such  degree  of  medianical 
compression  as  threatens  seriously  to  embarrass  cardiac  and  respiratory 
functions.  If  these  conditions  exist,  however,  removal  of  the  liquid 
should  be  performed  regardless  of  all  other  considerations. 

Riiles  for  the  Performance  of  Aspiration. — It  is  unnecessary  to 
discuss  at  length  the  modus  operan<li  of  aspiration.  The  necessity  for 
the  observance  of  aseptic  rules  with  reference  to  the  needle,  the  skin, 
and  the  hands  of  the  operator  are  too  well  understood  to  warrant  repeti- 
tion. It  is  perhaps  well  to  suggest  a  few  simple  precautions  which  I 
have  found  to  be  of  considerable  value.  These  relate  to  the  apparatus, 
to  the  position  of  the  patient,  the  site  of  puncture,  and  the  technic  of 
the  operation. 

1.  Let  it  be  adopted  as  a  carcUnal  and  invariable  rule  that  the  aspira- 
ting apparatus  should  be  overhauled  at  short  intervals  in  order  that 
it  may  be  constantly  in  admirable  working  order.  There  is  nothing 
more  humiliating  to  the  physician  than  to  prepare  the  invalid  for  aspira- 
tion, to  subject  him  to  the  mental  perturbation  incident  to  the  procedure, 
to  inflict  a  certain  amount  of  pain  upon  the  insertion  of  the  needle,  and 
then  chscover,  to  his  unutterable  chagrin,  that  the  apparatus  is  out  of 
repair.  After  a  troubled  anticipation  of  the  operation  antl  an  experience 
with  the  needle  not  to  say  pleasant,  the  invalid  is  unlikely  to  view  with 
perfect  complacency  the  failure  of  the  physician  to  have  the  apparatus 
in  complete  readiness.  Preparatory  to  each  aspiration  the  apparatus 
should  be  examined  with  care  and  its  working  efficiency  tested  both 
before  and  after  the  attachment  of  the  needle. 

2.  The  operation  should  be  performed  with  the  patient  in  a  sitting 
posture,  either  near  the  edge  of  the  bed  or  upon  a  chair  with  a  small 
table  conveniently  at  hand  upon  which  to  support  the  receiving  bottle. 
It  is  not  wise  to  perform  the  operation  with  the  patient  in  the  recumbent 
position  unless  forced  to  do  so  in  very  exceptional  instances.  The  hand 
of  the  affected  side  should  rest  upon  the  opposite  shoulder,  with  the 
elbow  thrown  as  far  forward  as  possible,  thus  widening  perceptibly  the 
intercostal  spaces.  The  patient  should  always  be  supported,  no  matter 
how  excellent  the  apparent  condition,  and  a  nurse  or  attendant  detailed 
to  note  carefully  the  character  of  the  pulse  during  the  operation.  It  is 
a  good  plan  to  administer  a  generous  alcoholic  stimulant  just  before  the 
insertion  of  the  needle.  In  the  event  of  nausea  and  vomiting,  faintness, 
or  irritating  cough,  the  aspiration  should  immediately  be  suspended. 
At  such  times  the  needle  should  be  completely  removed  for  the  time 
being,  although  coughing  will  frequently  subside  without  its  with- 
drawal if  the  removal  of  the  liquid  is  stopped  temporarily.  If  cough- 
ing persists  and  becomes  paroxysmal,  it  is  better  to  cease  operations 
altogether  and  reserve  further  aspiratory  efforts  for  a  future  time. 

3.  Various  regions  of  the  chest  have  been  advised  as  the  most  favor- 
able sites  for  paracentesis.  Some  clinicians  prefer  a  posterior  location, 
advocating  the  eighth  or  ninth  interspace  in  the  posterior  axillary 
line.  Others  aspirate  in  more  lateral  regions,  selecting  the  midax- 
illary  or  anterior  axillary  line  in  the  sixth  or  seventh  interspace. 
There  exists  no  conventional  site  for  operation  applicable  to  all  cases 
of  pleural  effusion.      Of  chief  importance  are  the  accurate  location 


TREATMENT  OF  SEROUS  EFFUSION  371 

of  the  exudate  by  means  of  the  physical  signs,  and  aspii-ation  over  the 
site  of  the  effusion.  In  large  general  pleural  exudates  the  precise  point 
of  puncture  is  not  always  of  material  consequence.  The  aspiration 
is  often  easier  in  the  more  lateral  regions  than  in  the  back,  as  the  rib- 
spaces  are  wider  and  the  chest-wall  thinner.  There  is,  however,  less 
likelihood  of  injuring  immecUate  structures  if  the  aspiration  is 
performed  in  the  lower  posterior  region,  preferably  in  the  eighth 
space,  in  the  scapular  line.  There  is  admittedly  more  diflficulty  in 
the  introduction  of  the  needle  at  this  point,  but  if  carefully  inserted, 
the  greater  thickness  of  the  muscular  wall  and  the  added  prox- 
imity of  the  ribs  are  of  minor  consequence.  The  selection  of  the  same 
point  for  aspiration  is  particularly  advantageous  in  cases  of  small  general 
effusions  because  of  their  invariable  location  at  the  base  as  shown 
in  Fig.  95.  Unless  the  puncture  is  made  in  the  lower  portion  of  the 
back,  not  far  from  the  scapular  line,  the  needle  will  be  inserted  con- 
siderably outside  of  the  effusion.  The  selection,  therefore,  of  such  an 
area  for  aspiration  is  peculiarly  advantageous  for  small  effusions,  and 
none  the  less  satisfactory  for  the  larger  exudates.  In  a  great  many 
instances  failure  to  observe  this  precaution  explains  a  negative  aspira- 
tion despite  an  actual  existence  of  the  effusion. 

In  the  circumscribed  pleurisies  so  frequent  among  consumptives, 
the  preferable  site  for  aspiration  is  the  place  where  the  signs  suggest 
the  presence  of  liquid,  regardless  of  its  location.  When  the  signs  are 
of  doubtful  interpretation,  a  degree  of  confirmatory  evidence  is  estab- 
lished by  the  presence  of  local  tenderness  upon  firm  pressure,  to 
which  consideration  Musser  has  recently  called  attention. 

4.  As  to  the  technic  of  the  operation,  it  is  well  to  exhaust  the  air 
from  the  receiving  bottle  before  the  insertion  of  the  needle.  The  best 
results,  however,  will  be  olitained  by  the  not  too  rapid  withdrawal  of 
the  exudate.  A  complete  negative  pressure  within  the  bottle  produces 
a  forceful  expulsive  stream  from  the  pleural  cavity.  It  is  sometimes 
attended  by  a  sudden  expansion  of  the  lung,  which  is  productive  of  disa- 
greeable symptoms.  Local  anesthesia  may  be  produced  satisfactorily  by 
a  spray  of  ethyl  chlorid,  which,  on  the  whole,  is  preferable  to  the  hypo- 
dermic injection  of  cocain  into  the  soft  parts.  The  needle  should  be 
introduced  slowly,  as  it  is  often  difficult  to  avoid  the  edge  of  a  rib.  If 
the  needle  is  inserted  in  this  manner,  no  damage  is  inflicted  either  to 
the  patient  or  to  the  neetlle,  which  is  not  always  the  case  in  the  event  of 
a  sudden  and  forceful  thrust.  It  is  well  to  keep  close  to  the  upper  margin 
of  the  rib  in  order  to  avoid  the  possible  danger  of  piercing  an  intercostal 
artery.  I  have  never  seen  this  accident  result,  but  have  known  of  its 
occurrence  in  a  single  case  resulting  in  the  death  of  the  patient,  the  nature 
of  the  accident  being  confirmed  by  autopsy.  The  distance  to  which  the 
needle  should  be  inserted  is,  of  course,  dependent  upon  the  age  of  the 
individual  and  the  thickness  of  the  outer  chest-wall.  A  consider- 
able resistance  to  the  point  of  the  needle  is  presented  by  the  pleura, 
which  is  frequently  tough  and  greatly  thickened.  After  some  experi- 
ence has  been  acquired  in  the  performance  of  aspiration,  the  physician 
is  enabled  to  recognize  when  the  pleura  has  been  pierced.  After  a 
portion  of  the  fluid  has  been  removed,  the  visceral  pleura  approaches 
more  and  more  the  parietal  layer,  and  in  many  instances  becomes  lacer- 
ated by  the  point  of  the  needle,  unless  due  precaution  is  taken  to  avoid 
this  occurrence.     F()r  this  reason  the  needle,  after  its  insertion,  should 


372  COMPLICATIONS 

not  be  permitted  to  remain  unsupported  by  the  hand  of  an  attendant  or 
of  the  operator.  The  proximal  extremity,  with  the  attached  tube,  should 
rest  gently  in  the  open  hand  in  order  to  give  it  support  and  maintain  its 
position  at  a  right  angle  to  the  chest-wall.  In  this  way  it  is  compara- 
tively easy  to  recognize  the  instant  that  the  visceral  pleura  impinges  upon 
the  point,  and  early  opportunitj'  is  afforded  for  the  partial  withdrawal  of 
the  needle  before  damage  is  inflicted.  A  very  slight  withdrawal  is  advis- 
alile  after  the  remowil  of  about  twelve  ounces  of  liquid,  in  anticipation 
of  the  nearer  approach  of  the  lung  to  the  chest -wall.  It  is  never  wise 
to  remove  over  thirty-two  ounces  at  one  time,  and  in  many  cases  a 
smaller  amount  is  preferable.  Upon  cessation  of  the  stream  a  recurring 
flow  may  be  obtained  b\-  lifting  the  outer  end  of  the  needle,  thus  depress- 
ing the  point.  This  sometimes  occasions  a  little  cUscomfort  to  the 
patient,  but  often  permits  the  removal  of  considerably  more  exudate 
without  necessitating  a  lower  puncture.  It  is  not  advisable  to  exhaust 
the  air  in  the  receiving  bottle  during  the  act  of  aspiration.  If  the  stream 
becomes  scanty,  it  is  well  to  turn  the  stopcock  in  the  tube  and  prevent 
free  communication  with  the  pleural  cavity  before  the  air  is  further 
exhausted  within  the  bottle.  It  is  not  ailvisable  to  attempt  the  re- 
moval of  a  plem-al  effusion  without  the  presence  of  at  least  a  nurse 
or  attendant.  Extreme  faintness  on  the  part  of  the  patient  is  by  no 
means  infrequent.  I  recollect  one  instance  in  which,  during  the  aspira- 
tion of  a  medical  student,  an  accompanying  relative  who  was  rendering 
assistance  suddenly  fainted,  and  the  patient  shortly  after  experienced 
a  remarkably  severe  epileptic  convulsion.  Fortunately,  I  was  able  to 
withdraw  the  needle  without  accident  as  the  patient  fell,  and  no  serious 
injury  was  inflicted,  but  the  lesson  is  apparent  that  the  patient  should 
alwa_ys  be  supported  and  the  general  condition  constantly  noted  by  a 
competent  assistant. 

It  is  advocated  by  some  to  delay  aspiration  until  fever  has  ceased,  on 
the  ground  that  the  rise  of  temperature  indicates  a  continuance  of  inflam- 
matory action,  and  presupposes  a  recurrence  of  the  effusion.  If,  however, 
indications  for  removal  relating  to  the  pidse  and  respiration  are  per- 
fectly chvir.  asjijration  should  be  performed  regardless  of  fever.  On  the 
other  liainl.  a  [xM-iistiu^  fever  attending  a  moderate  effusion  without 
other  clinical  iiiaiiitostations  suggests  the  expediency  of  operation. 
Without  the  exhibition  of  so  clearly  defined  data  there  is  no  excuse 
for  resorting  to  the  aspirating  needle,  even  to  the  extent  of  an  explora- 
tory puncture.  Those  who  regard  as  a  myth  the  danger  of  converting 
a  serous  effusion  into  a  purulent  one  by  the  introduction  of  the  needle 
have  certainly  been  most  fortunate  in  their  technic  or  have  had  but 
little  experience.  Several  times,  after  a  scrupulous  disinfection  of  skin 
and  hands,  the  introduction  of  an  a.septic  needle  has  been  sufficient  to 
convey  an  infection  into  the  pleural  cavity  with  unfortimate  .sequelae. 
The  use  of  the  exploratory  needle  for  purely  diagnostic  purposes  is 
entirely  without  any  justification  in  these  cases.  Given  a  ca.se  of  pleu- 
ral effusion  of  any  nature  and  extent,  if  the  clinical  indications  for  its 
removal  be  sufficiently  clear,  ordinary  aspiration  may  be  employed.  With 
the  adcUtional  information  secured  through  the  gross  appearance  and  the 
bacteriologic  examination  of  the  exudate,  a  sub.sequent  cour.se  of  pro- 
cedure can  be  .safely  and  intelligently  conducted.  If,  however,  upon  the 
merits  of  the  clinical  s}'mptoms  the  indications  do  not  demand  removal, 
meddlesome  and  dangerous  interference  should  not  be  indulged  in  simply 


EMPYEMA  373 

for  the  purpose  of  diagnosis,  which  for  the  moment  is  relatively  unimpor- 
tant. Contrary  to  the  opinion  entertained  by  some  that  the  character 
of  the  treatment  is  chrectly  dependent  upon  the  nature  of  the  effusion, 
let  it  be  asserted  that  among  consumptives  the  question  of  entering 
the  pleural  cavity  should  be  decided  strictly  upon  the  combination  of 
symptoms  and  physical  signs.  In  all  such  cases  these  may  furnish  suffi- 
cient data  to  constitute  a  safe  working  basis  without  recourse  to  that 
refinement  of  diagnosis  which  exalts  the  findings  of  the  laboratory  and 
the  autopsy  at  the  expense  of  the  patient.  If  the  clinical  manifestations 
warrant  the  performance  of  aspiration,  or  assuming  that  the  pleural 
cavity  has  already  been  entered,  it  is  conceded  that  the  future  manage- 
ment is  subject  to  some  extent  to  the  character  of  the  effusion.  The 
present  contention  is  simply  that  among  pulmonary  invalids  the  precise 
determination  of  the  nature  of  the  liquid  by  routine  exploratory  puncture 
is  entirely  unnecessary  as  regards  a  future  course  of  action,  in  view  of  the 
guidance  and  direction  afforded  by  other  means. 


CHAPTER   LIV 
EMPYEMA 


Clinical  Manifestations. — Before  prnci.cilin^  dii-octly  to  the  treat- 
ment of  purulent  pleurisies  it  is  well  to  i;ill  nilcininn  Inicliy  to  certain 
features  of  symptomatology  and  diagnosis  w  liicli  uic  (•s]ieci;i,lly  common 
to  this  variety. 

On  account  of  the  presence  of  unyielding  adhesions,  circumscribed 
empyema  is  more  frequent  among  consumptives  than  among  non-tuber- 
culous individuals.  Circumscribed  purulent  exudates  may  exist  not 
only  between  the  lung  and  the  chest-wall,  but  also  between  the  dia- 
phragm and  the  lung  or  the  separate  lobes  of  the  lung.  Empyema  may 
result  from  caries  of  rib  or  vertebra,  serous  pleurisy,  or  au  iiiiiTiniiing 
pneumonia  and  typhoid.  Allusion  has  been  made  to  ilic  im-t  tliat 
effusions  of  this  character  may  be  of  gradual  or  of  acute  unset,  arcom- 
panied  in  some  cases  with  general  systemic  infection,  and  in  others  with- 
out the  slightest  evidence  of  constitutional  disturbance.  The  younger 
the  patient,  the  more  likely  are  the  symptoms  to  be  acute  in  nature. 
Cases  associated  with  systemic  infection  are  characterized  by  chills, 
fever,  sweats,  and  frequently  leukocytosis.  Cases  exhibiting  marked 
septic  phenomena  are  usually  of  streptococcic,  pneumococcic,  or 
staphylococcic  origin.  Pain  is  comparati\<l\-  unimportant,  other  than 
it  may  at  times  afford  an  indication  of  the  imilialile  site  of  the  infection. 
Localized  tenderness  is  of  much  greater  inipoitaiice  than  pain.  Musser 
lays  great  stress  \]]<im  firm  and  deep  pre.ssure  in  the  interspaces  in  an 
effort  to  elicit  a  ]>oiiit  of  tenderness  which  may  suggest  the  site  of  the 
empyema.  Purulent  effusions,  however,  often  exist  entirely  devoid  of 
any  rational  symptoms  suggestive  of  their  presence.  Their  early  recog- 
nition necessitates  painstaking  examinations  of  the  chest,  which  should 
be  repeated  at  short  intervals. 

Among  pulmonary  invalids  unilateral  immobility  of  the  chest-wall 
or  a  localized  impairment  of  expansion  is  of  much  less  significance  than 


374  COMPLICATIONS 

among  the  non-tuberculous,  because  of  other  pathologic  changes  cap- 
able of  producing  a  limited  respiratory  movement.  The  attention  of 
the  examiner,  however,  may  be  directed  by  this  means  to  detailed  phy- 
sical investigation.  Edema  of  the  chest-wall  is  sometimes  present, 
though  not  a  constant  accompaniment  of  empyema.  In  some  cases  the 
pus  accumulation  may  rupture  spontaneously  into  a  bronchial  tube  and 
be  discharged  through  the  mouth  in  large  quantities,  or  produce  death 
from  inundation  of  the  bronchial  tract.  Rarely,  the  purulent  exudate 
may  point  externally  and  be  evacuated  in  this  manner— the  so-called 
"empyema  necessitatis."  Among  consumptives  the  vocal  freniitus  in 
interlobar  empyemas  is  vague  and  capable  of  misinterpretation,  on 
account  of  the  transmission  of  the  vibrations  through  areas  of  pulmo- 
nary consolidation. 

A  consideration  of  some  importance  pertaining  to  percussion  signs 
in  such  cases  is  the  relation  of  the  area  of  dulness  to  the  interlobar  septa. 
Musser  has  been  particularly  successful  in  localizing  purulent  empyemas 
by  following  the  lines  of  the  septa.  He  reports  the  area  of  dulness  well 
below  the  lobar  fissures  in  cases  in  which  the  empyema  exists  deeply 
between  the  lobes.  Despite  the  absence  of  breath-  and  voice-sounds  over 
a  given  area  it  is  not  especially  infrequent  to  distinguish  in  these  cases  an 
increased  skodaic  tympany. 

On  account  of  the  antecedent  pathologic  changes  in  the  lung  and 
pleura  among  pulmonary  invalids,  but  little  importance  need  be  attached 
to  the  shape  or  location  of  the  pleural  effusion. 

An  auscultatory  feature  of  special  interest  in  connection  with  the 
small  empyemas  of  consumptives  is  the  remarkable  frequency  with 
which  moist  bubbling  rales  are  transmitted  with  perfect  clearness 
through  a  considerable  effusion.  This  phenomenon  has  frequently  led 
to  errors  in  diagnosis  because  of  the  inference  that  the  presence  of  loud 
bulsbling  rales  is  incompatible  with  an  effusion. 

Exploratory  Puncture. — The  possible  dangers  attending  exploratory 
puncture  are  more  practical  than  is  usually  supposed.  The  negative 
results  which  so  often  attend  its  employment  are,  to  say  the  least,  mis- 
leading, and  permit  of  dangerous  delaj's.  This  line  of  remark  with 
reference  to  the  inadvisability  of  paracentesis  for  diagnostic  purposes  is 
not  to  be  construed  as  opposing  aspiration  with  a  large-sized  needle 
whenever  the  symptoms  and  physical  signs  suggest  the  expediency  of 
such  undertaking.  I  would  sooner  resort  to  efficient  surgical  explora- 
tion of  a  suspicious  area,  provided  the  subjective  and  objective  signs 
were  sufficiently  clear,  than  to  dismiss  such  interference  solely  on  the 
evidence  of  repeated  negative  exploratory  puncture. 

It  is  unwise,  however,  to  acce])t  the  more  or  less  radical  position 
assumed  by  some  in  favor  of  siiruir;il  in\csli<::iticin,  unless  there  is  clinical 
evidence  of  an  undoubted  Idi-ili/i'd  Incus  <ii'  infection.  Certain  it  is 
that  the  chest  cannot  be  opriuMl  m\<\  ('\|i|(.iv.1  with  the  same  impunity 
as  the  abdomen,  on  account  of  \\\r  |Mi-Ml>;liiv  of  iinliu-iuii  a,  dangerous 
pneumothorax.  I  will  cite  luidl)'  :ui  inicirsi  nui  cxikm  icucc  wliich  illus- 
trates the  difficulties  so  fr(M|uciul\-  ciuDiiiniMcd  ui  tlu>  diagnosis  and 
management  of  intrathoracic  disease. 

The  patient  was  a  w-oman  of  twenty-seven  years  who  came  to  Colorado 
from  Tennessee  on  account  of  suspected  pulmonary  tuberculosis.  Her 
illness  had  been  of  six  months'  duration,  following  an  acute  onset  which 
was  characterized  by  severe  pleuritic  pain  lasting  nearly  six  weeks. 


EMPYEMA  375 

There  had  been  much  loss  of  strength  and  flesh,  with  constant  fever  and 
severe  cough,  the  expectoration  being  purulent  and  amounting  to  about 
six  ounces  daily.  Upon  arrival  she  was  markedly  anemic,  emaciated, 
and  experienced  moderate  dyspnea  upon  slight  exertion,  the  temperature 
ranging  between  102°  and  103°  F.,  and  the  pulse  from  120  to  130.  There 
were  almost  daily  chills.  Upon  examination  the  respiratory  movements 
upon  the  right  side  were  found  somewhat  limited.  There  was  moderate 
dulness  in  the  back  from  the  spine  of  the  scapula  to  the  base;  also  in 
front  from  the  fourth  rib  to  the  base,  and  in  the  axilla.  Respiratoiy 
sounds  throughout  this  region  were  cnlVcMed  and  markedly  distant. 
There  was  complete  absence  of  vocal  ficinit  us  and  vocal  resonance.  The 
symptoms  and  signs  pointed  to  an  iui  lallidiacic  pus-collection,  probably 
of  pleural  origin.  Aspiration  was  practised  in  the  eighth  interspace  in 
the  line  of  the  angle  of  the  scapula  with  negative  result.  This  was 
repeated  several  times  during  the  ensuing  week,  until  at  least  seven  or 
•eight  punctures  had  been  made.  Despite  failure  to  discover  pus  it  was 
impossible  to  entertain  any  other  chagnosis  than  that  of  ah  abscess  within 
the  chest.  It  was  determined  to  explore  the  lung  itself,  but,  owing  to 
inability  to  elicit  tenderness  at  any  point,  or  to  detect  a  sharply  circum- 
scribed area  of  flatness,  it  was  somewhat  difficult  to  select  a  site  for 
deep  exploration.  The  needle  was  inserted  nearly  to  its  full  length 
(four  inches)  at  a  point  just  below  and  slightly  within  the  lower  angle  of 
the  scapula.  Something  less  than  an  ounce  of  pus  was  withdrawn,  which 
was  found  to  be  of  streptococcic  nature.  One  or  two  days  subsequently 
rib  resection  was  performed  at  this  point  by  Dr.  Charles  A.  Powers. 
Extremely  firm  and  extensive  pleural  adhesions  entirely  obliterated  the 
pleural  cavity  at  the  site  of  operation.  The  insertion  of  the  needle  through 
the  deeply  injected  pleura  into  the  lung  resulted  in  the  withdrawal  of 
one-half  teaspoonful  to  one  teaspoonful  of  pus.  A  deep  incision  was 
made  into  the  lung,  and  was  followed  by  moderate  finger  curetage.  All 
the  lung  tissue  within  reach  of  the  finger  was  found  honeycombed  with 
very  small  pus-cavities.  The  trabecule  were  broken  down  as  much  as 
possible  with  the  finger,  and  a  single  pulmonary  cavity,  the  size  of  a 
small  orange,  was  produced  into  which  drainage-tubes  were  inserted. 
There  was  no  elevation  of  temperature  following  the  operation.  The 
patient  gained  thirty-five  pounds  in  weight,  assumed  a  healthy  appear- 
ance, and  was  sent  home  at  the  end  of  three  and  one-half  months  in 
excellent  general  condition,  the  physical  signs,  howe\'er,  remaining 
practically  unaltered.  Advices  received  from  her  attending  surgeon 
in  Nashville,  Dr.  McGannon,  are  to  the  effect  that  her  general  condition 
remains  excellent,  although  the  abscess  is  discharging  slightly.  She 
has  had  one  or  two  slight  hemorrhages  following  paroxysmal  cough. 
The  site  of  the  operation  is  shown  in  the  accompanying  photograph 
(Fig.  104),  taken  shortly  after  her  return.  The  extent  of  pathologic 
change  in  the  lung  is  seen  in  the  skiagraph  recently  made.  The  impor- 
tant lesson  to  be  learned  from  such  an  experience  is  to  the  effect  that 
exploratory  operation  should  lie  resort  id  lo  despite  negative  punc- 
tures, provided  the  symptoms  and  siun-  point  strongly  toward  an  intra- 
■  thoracic  pus-collection.  I  know  this  to  lie  coni  rar>-  to  the  teaching  of 
many  surgeons,  who  decline  to  extend  o|iirai  i\  c  micrference  in  thoracic 
cases  unless  a  verification  of  the  condition  is  alToidcd  by  the  use  of  the 
needle.  It  is  easy  to  appreciate  that  in  this  case  pus  might  not  have 
been  discovered  even  after  numerous  attempts  at  aspiration.     In  siich 


376  COMPLICATIONS 

event  the  patient  must  have  inevitably  proceeded  to  a  rapidly  fatal  issue. 

Among  consumptives  a  decision  relative  to  the  expediency  of  explo- 
ratory puncture  is  in  many  cases  extremely  difficult.  As  a  general 
rule,  routine  recourse  to  the  use  of  the  exploring  needle  as  a  means  of 
diagnosis  is  productive  of  less  satisfactory  results  than  are  obtained  by 
reserving  aspiration  for  those  cases  exhibiting  positive  surgical  indica- 
tions for  its  employment. 

Methods  of  Treatment. ^In  former  years  it  was  the  general  dictum 
of  the  medical  profession  that  the  treatment  of  all  cases  of  empyema 
should  be  that  of  surgical  interference,  the  only  difference  of  opinion 
relating  to  the  choice  of  method.  It  may  be  of  interest  to  quote  brief 
extracts  from  a  paper  prepared  by  me  thirteen  years  ago,  and  deter- 
mine to  what  extent  one  can  indorse  the  views  then  entertained. 

"The  important  practical  thought  to  be  emphasized  in  this  connec- 
tion is  the  recognition  of  the  existence  of  several  species  of  bacteria  in 


Fig.  104. — Showing  site  of  operation  in  pulmonary  abscess  with  recover>'.     (Compare  with  radio- 


the  exudate,  endowed  with  varying  properties  and  possessing  marked 
differences  in  their  virulence.  The  most  benign  of  these  characterize 
the  empyemas  of  chiklren  and  the  metapneumonic  pleurises  of  atlults, 
and  thereby  furnish  to  the  physician  a  justification  for  not  resorting 
immediately,  in  all  instances,  to  the  more  radical  and  nuitilative 
measures  of  treatment.  The  therapeutic  indications  are  conceded  to 
be,  first,  prompt  and  thorough  evacuation  of  the  pus;  second,  prevention 
of  reaccumulation  by  means  of  free  and  continuous  drainage;  third,  the 
maintenance  of  asepsis;  and,  finally,  the  obliteration  of  the  pus-secreting 
cavity  through  adecjuate  provision  for  the  expansion  of  the  lung  and 
the  collapse  of  the  chest-wall.  Save  in  extreme  cases  a  general  tuber- 
culous infection  never  contraindicates  an  operation  from  which  satisfac- 
tory results  are  frequently  obtained." 

A  single  preliminarn  aspiration  was  advocated  in  children  and  in  the 
metapneumonic  pleurisies  of  adults.     This  was  not   based  upon  any 


EMPYEMA  377 

faith  in  the  adequacy  of  aspiration  to  effect  a  cure,  but  rather  with  an 
aim  to  afford  temporary  relief,  and  at  the  same  time  to  establish  a 
definite  diagnosis.  The  purulent  nature  of  the  effusion,  particularly 
in  adults,  was  thought  almost  invariably  to  demand  subsequent  opera- 
tive measures.  Free  opening  of  the  pleural  cavity  was  strongly  recom- 
mended on  account  of  the  complete  exit  offered  to  the  coagula  and 
organic  debris,  and  the  much  improved  facilities  for  a  continuous  dis- 
charge. Save  for  the  employment  of  the  single  preliminary  aspiration 
in  children,  this  method  was  urged  as  an  initial  procedure  in  the  treat- 
ment of  all  cases  of  empyema  regardless  of  other  qualifying  conditions. 
It  was  insisted  that  if  resection  of  rib  was  more  frequently  employed 
in  the  early  stages  of  empyema  before  opportunity  was  afforded  for 
the  development  of  unfavorable  conditions,  there  would  result  far  less 
frequently  the  necessity  for  recourse  to  so  severe  a  procedure  as  the 
multiple  rib  resection. 

For  several  years  the  conclusions  which  were  largely  derived  from 
the  experience  of  others  were  conscientiously  applied  to  appropriate 
cases  of  tuberculosis,  with  almost  iii\ariably  unfortunate  results.  The 
essential  principle  of  tre;itni(iii  w.is  to  perform  pleurotomy,  provided  the 
general  condition  of  the  ciiiiMinijiiiNc  was  not  materially  impaired, 
regardleiss  of  such  vitally  iinpoii  .-mt  ron^iderations  as  fever,  chills,  sweats, 
and  emaciation.  If  the  coiiditioii  of  the  i);iti('iit  in  f;ir-:iii\;iiiced 
phthisis  was  desperate,  it  \\;is  tluiuulii  iiuui'  inciiilul  to  jicrinit  liiiii  to 
die  without  inflicting  the  added  toi-tiivc  of  an  o])crati()n.  In  the  light 
of  a  considerable  cxpciicnci'  il  luis  become  apparent  that  the  previ- 
ous course  was  dircrHy  and  ladically  wrong.  Cases  will  be  reported 
at  length  in  order  t(i  illu.^tiate  the  great  responsibility  assumed 
in  advocating  a  radical  operation  for  those  comparatively  well,  and  in 
withholding  such  surgical  aid  from  others  in  urgent  need,  though 
apparently  beyond  hope.  It  is  well  to  bear  in  mind  that  rib  resection 
is  necessarily  followecl  by  one  of  two  conditions.  There  either  takes 
place  a  considerable  expansion  of  the  previously  compressed  lung,  which 
affords  opportunity  for  renewed  acti^'it.y  of  the  tuberculous  process  and 
rapid  cavity  formation,  or  there  de^•elops  failure  of  the  lung  to  expand, 
involving  long-continued  pus-formation  and  great  danger  of  amyloid 
change.  In  the  absence  of  such  clinical  indications  as  fever,  sweats,  and 
chills  it  seems  exceedingly  ill  considered  to  precipitate  the  patient  into 
the  midst  of  such  peril. 

In  1895  a  young  man,  a  patient  of  Dr.  F.  C.  Shattuck,  con- 
sulted me  immediately  upon  arrival  in  Colorado,  exhibiting  moder- 
ate tuberculous  infection  of  the  right  lung.  His  illness  had  been  of 
fourteen  months'  duration,  the  first  symiitoms  relati\-e  to  the  pulmo- 
nary involvement  beginning  October,  INOl.  (  dui^li  and  expectoration 
were  moderate.  There  was  slight  dailx  I'lcvaiion  of  temperature, 
with  some  acrcleration  of  the  pulse,  flxanmiatiim  of  the  chest  dis- 
closed moist  vMi-<  in  the  right  lung  from  the  apex  to  the  third  rib. 
After  a  peri'id  <>l'  scxcral  weeks  a  pleural  effusion  was  recognized 
and  thirty  ounces  of  sterile  serous  exudate  were  withdrawn.  Subse- 
quently the  fluid  was  removed  many  times  .it  intei'v.uls  of  from  three  to 
six  weeks.  In  the  light  of  my  present  cdin  irtions  this  procedure  was 
quite  unwarranted.  There  had  developed  no  increased  elevation  of 
temperatu-e,  no  greater  rapidity  of  pulse,  or  other  constitutional  disturb- 
ance suggesting  its  removal.     Upon  the  other  hand,  the  general  condition 


378  COMPLICATIONS 

after  the  advent  of  the  effusion  was  considerably  imjDroved.  Chills 
and  sweats  were  absent,  and  there  was  no  evidence  of  respiratory  or 
cardiac  embarrassment.  In  this  case  the  controlling  indication  for  the 
removal  of  liquid  was  believed  to  be  the  continiious  presence  of  a  large 
inflammatory  exudate,  which  proved  incapable  of  absorption.  It  was 
thought  that  no  good  could  result  from  the  presence  of  even  a  sterile  fluid 
in  the  pleural  cavity,  and  possibly  considerable  harm  from  the  consequent 
lung  compression  and  other  pathologic  changes.  The  position  was  as- 
sumed that  a  case  exhibiting  progressive  improvement  both  in  the  physi- 
cal signs  and  general  condition  was  endowed  with  an  excellent  prognosis, 
and  hence  was  vested  with  greater  responsibilities  than  would  have  been 
true  of  a  less  favorable  conchtion.  Accordingly,  it  seemed  rational  to 
prevent  continuous  lung  compression  even  by  a  fluid  thus  far  unpro- 
ductive of  subjective  disturbances.  It  was  not  appreciated  that  a 
measure  of  the  improvement  in  the  general  condition  and  physical 
signs  might  justly  be  attributed  to  the  very  fact  of  the  compression. 
Unfortunately,  the  effusion,  whether  or  not  by  virtue  of  repeated 
aspirations,  finally  was  converted  from  a  serous  into  a  purulent  one. 
This  change  in  the  character  of  the  exudate  was  not  accompanied 
by  the  least  evidence  of  systemic  disturbance,  and  upon  the  score  of 
the  general  condition  the  necessity  of  an  empyema  operation  was  not 
apparent.  Pus,  however,  was  known  to  be  present  in  the  pleural  cavity, 
and  this  was  believed  to  constitute  an  imperative  indication  for  its 
evacuation  and  subsequent  drainage.  Single  rib  resection  was  per- 
formed by  Dr.  Powers.  From  the  standpoint  of  the  intrapleural  pus 
accumulation  the  operation  was  satisfactory  to  a  degree,  drainage  was 
perfect,  and  the  lung  expanded  to  a  very  considerable  extent.  Judged 
from  the  basis  of  the  individual,  however,  the  remote  effects  of  tlie 
operation  were  extremel.y  disastrous.  With  the  pulmonary  expansion 
there  ensued  a  perceptible  increa.se  in  the  activity  of  the  tidierculous 
process.  The  bronchial  rales  became  coarser  anfl  bubbling  in  char- 
acter. Cough  increased  materially,  and  expectoration  became  more 
profuse.  Fever,  impairment  of  appetite,  and  emaciation  were  attended 
by  rapid  softening  and  excavation  until  the  decline  was  terminated  by 
death.  The  peculiarly  instructive  feature  of  this  case  is  the  fact  that 
the  improvement  in  the  general  condition  was  uninterrupted  up  to  the 
time  of  the  operative  interference,  and  the  subsequent  retrogression 
rapid  and  relentless.  After  several  similar  experiences  the  conclusion 
has  been  forced  that  in  the  absence  of  pronounced  septic  infection  afford- 
ing distinct  indications  for  operation,  the  interests  of  the  patient  are 
better  subserved  for  the  time  being  by  non-interference.  It  goes  with- 
out saying  that  under  circumstances  similar  to  the  case  just  cited,  it  is 
somewhat  difficult,  upon  the  score  of  actual  results,  for  the  lay  mind  of 
patient  and  friends  to  acquiesce  in  the  rationale  of  the  operation. 

Another  case  is  that  of  a  man,  aged  twenty-eight,  who  had  resided 
in  Colorado  one  and  one-half  years  before  coming  under  my  obser- 
vation, November,  1899.  A  progressive  decline  had  been  displayed 
from  the  beginning.  He  had  been  bedridden  for  several  months,  and 
a  speedy  fatal  termination  was  predicted  by  two  physicians  who 
had  Ijeen  in  attendance.  For  many  weeks  there  had  occurred  daily 
chills,  succeeded  Ijy  sharp  elevations  of  temperature,  which  in  turn  were 
followed  by  severe  sweats.  Cough  was  .severe  and  distressing,  ex- 
pectoration purulent  and  copious,  and  the  appetite  had  failed  entirely. 


EMPYEMA  379 

I  found  the  patient  apparently  moribund.  There  were  extreme  emacia- 
tion and  cachexia.  The  countenance  was  drawn  and  ashen,  with 
pinched  features,  the  entire  face  being  covered  with  cold  perspiration. 
The  pidse  was  exceedingly  weak,  scarcely  palpable,  and  constantly  over 
150,  while  dyspnea  was  marked.  Upon  examination  extensive  tuber- 
culous infection  was  recognized  in  the  right  lung,  together  with  a  mod- 
erate involvement  of  the  left.  A  small  circumscribed  pleural  effusion 
was  detected  at  the  right  base,  which  was  found  by  exploratory  punc- 
ture to  be  purulent  in  character.  Arrangements  were  made  for  an 
immediate  rib  resection,  although  it  was  believed  that  any  effort  in  this 
direction  would  be  utterly  unavailing  as  far  as  the  saving  of  life  was 
concerned.  The  position  was  assumed  that  the  sepsis  and  prostration 
were  directly  dependent  upon  the  contained  pus,  and  that  the  invalid, 
in  spite  of  his  extremity,  was  legitimately  entitled  to  the  adoption  of 
the  same  energetic  measures  as  a  non-consumptive.  The  patient  and 
family,  who  were  quite  conversant  with  the  desperate  nature  of  the  con- 
dition, were  made  acquainted  with  the  radical  treatment  advised.  The 
surgeon  who  was  summoned  to  perform  immediate  rib  resection  was 
amazed  at  the  condition  of  the  patient,  and  declined  to  render  surgical 
assistance  upon  the  ground  that  the  invalid  was  a  hopeless  consumptive 
at  best.  In  view  of  the  fact,  however,  that  I  was  committed  to  the  oper- 
ation, he  reluctantly  consented  to  extend  surgical  assistance,  although 
contrary,  as  stated,  to  the  ethics  and  principles  of  surgery  applicable  to 
the  empyemas  of  far-:1d^•an(■ed  consumption.  Nearly  20  ounces  of  pus 
were  evacuatt'd,  :in(l  the  fiiiiicr  inserted  through  the  chest-wall  demon- 
strated the  ciiiuiiisciilicil  luiiiiic  of  the  empyema.  After  the  operation 
the  patient  renuuncd  utterly  piostrated  for  many  weeks,  but  a  slow  and 
gradual  improvement  subsequently  took  place.  The  wound  closed  in  six 
months  after  the  operation.  After  convalescence  became  established  the 
patient  was  kept  constantly  in  the  open  air,  subjected  to  superalimenta- 
tion, and  gradually  achieved  a  pronounced  gain  in  nutrition.  This  was 
followed,  after  several  years,  by  an  entire  arrest  of  the  tuberculous 
process.  During  the  past  seven  years  the  patient  has  devoted  himself 
assiduously  to  indoor  work,  and  the  arrest  of  the  pulmonary  infection 
is  apparently  permanent  and  complete.  Some  idea  as  to  the  subsequent 
result  may  be  obtained  by  reference  to  the  accompanying  photograph, 
recently  taken  (Fig.  105). 

It  is  well  to  report  another  case,  of  more  recent  occurrence,  which 
illustrates  almost  equally  the  possibilities  of  confusion  in  diagnosis, 
and  the  justification  for  radical  operation,  notwithstanding  extreme 
physical  debility.  The  patient,  aged  thirty-six,  arrived  in  Colorado 
November  24,  1906,  and  consulted  me  upon  the  following  day.  Her 
illness  had  been  of  one  year's  duration,'  a  progressive  decline  being 
characterized  by  distressing  cough,  moderate  expectoration,  extreme 
exhaustion,  pallor,  and  emaciation.  In  a  letter  from  her  pliysician  it 
was  stated  that,  after  a  futile  effort  to  seciu-e  improvement  at  home, 
she  was  sent  to  Colorado  as  a  last  resort,  though  without  any  reason- 
able hope  as  to  her  improvement.  Her  temperatm-e  was  descriljed 
as  having  been  continuously  high  throughout  the  period  of  observa- 
tion, and  her  pulse  exceedingly  rapid.  The  general  appearance  upon 
arrival  was  assuredly  suggestive  of  a  highly  desperate  condition,  but 
some  valid  ground  for  hope  was  established  by  the  recognition  of  a 
small  circumscribed  and  irregular  area  of  flatness  in  the  left  back,  with 


380  COMPLICATIONS 

diminution  of  breath-sounds  and  vocal  resonance.  Pus  was  obtained 
upon  aspiration,  and  the  patient,  despite  her  unfavorable  contUtion, 
committed  to  immetliate  rib  resection  which  was  performed  by  Dr. 
F.  L.  Dixon.  About  twelve  ounces  of  pus  of  staphylococcic  origin  were 
evacuated.  Upon  rallying  from  the  operation  there  was  manifested 
a  remarkable  improvement  in  all  respects.  Coincidently  with  the 
obliteration  of  the  pus-cavity  there  was  a  complete  disappearance  of 
physical  signs  attributable  to  pulmonary  involvement.  After  a  gain 
of  thirty  pounds  in  weight,  the  former  health  was  apparently  restored 
and  the   mother  of  five  young   children  was  returned  to  her  family. 


Fig.  105. 

ation  for  empyema 

Fig.  77,  p.  281). 

The  site  of  the  circumscriljed  empyema  is  represented  by  the  percus- 
sion outlines  shown  in  Fig.  106,  which  is  of  added  interest  in  connec- 
tion with  the  skiagraph  showing,  eight  weeks  after  operation,  an  entire 
absence  of  shadow  change. 

To  witness  a  rapidly  progressive  decline,  with  a  fatal  termination, 
in  one  who  before  operation  was  well  nourished,  devoid  of  fever,  to  out- 
ward appearances  in  good  condition;  to  observe  the  astonishing 
recovery  from  an  empyema  in  one  who  at  first  was  refu.sed  operation  as 
being  almost  moribund,  and  to  note  a  permanent  restoration  to  health 
in  others,  is  sufficient  to  shake  one's  faith  in  the  tenability  and  wisdom 
of  previously  accepted  principles  pertaining  to  a  course  of  treatment 
accorded  pulmonary  invalids.  Other  equally  conspicuous  cases  could 
be  reported,  if  necessary,  to  demonstrate  the  correctness  of  these  con- 
clusions. 

My  present  custom  in  the  empyema  of  consumptives  is  to  let  it  alone 
unless  there  is  some  good  and  sufficient  cause  for  interference  along  the 
lines  previously  suggested.     If  rcnioxa!  is  indicated,  simple  aspiration 


EMPYEMA  381 

is  employed,  and  repeated  as  frequently  as  demanded.  The  only  excep- 
tion to  this  relates  to  thoroughly  septic  cases,  exhibiting  chills,  fever, 
sweats,  and  great  prostration.  Under  such  conditions  no  time  should  be 
lost  through  temporizing  measures  in  securing  free  opening  and  thorough 
drainage.  Occasionally  it  is  expedient,  however,  to  excise  the  rib  and 
drain  a  small  well-circumscribed  empyema  even  in  the  absence  of  septic 
manifestations  provided  the  tuberculous  process  is  very  slight. 

It  is  unnecessary  to  describe  in  detail  distinctly  surgical  procedures. 
It  may  be  permissible,  however,  to  call  attention  to  one  or  two  features 
that  have  repeatedly  impressed  me  as  of  great  importance.  First,  the 
opening  should  not  be  too  low,  in  order  that  it  may  not  be  later  closed 
by  the  rising  diaphragm.  The  pus  is  not  emptied  from  the  thorax 
altogether  through  the  force  of  gravity,  but  is  pumped  out  to  a  large 
extent  by  the  action  of  the  lung  in  inspiration  and  expiration.     Secondly, 


the  opening  should  be  maintained  sufficiently  patulous  to  permit  free 
drainage.  This  does  not  refer  alone  to  the  opening  in  the  chest-wall, 
but  to  the  tubes  as  well.  Many  times  I  have  seen  fenestrated  tubes 
when  kept  in  position  for  a  prolonged  period  completely  occluded  by 
a  growth  of  granulation  tissue.  Third,  the  tube  should  be  removed 
daily  and  cleansed,  as  well  as  shortened  from  time  to  time,  in  order  to 
permit  the  fullest  possible  drainage,  and  to  avoid  the  violent  paroxysms 
of  coughing  produced  by  irritation  of  the  approaching  visceral  pleura. 
Conspicuous  relief  from  distressing  paroxysms  of  cough  may  be  afforded 
by  frequent  shortenina;  of  the  tube.  Fourth,  daily,  after  removal  of  the 
tube,  the  patient  should  not  merely  be  turned  on  the  side,  but  should  also 
be  subjected  to  a  short  series  of  pulmonary  gymnastics  in  various  posi- 
tions. This  permits  the  fullest  possible  drainage,  which,  as  a  rule,  is 
not  attained  by  ordinary  turning  of  the  patient.  Gentle  coughing  is 
often  sufficient  at  such  a  time  to  expel  violently  large  masses  of  floccu- 


a»Z  COMPLICATIONS 

lent  coagula,  or  at  least  to  cause  them  to  appear  at  the  opening  and 
allow  their  subsequent  removal  by  the  forceps. 

Irrigation  need  not  be  employed  save  under  quite  exceptional  con- 
ditions. It  is  permissible  to  irrigate  with  salt  solution  from  time  to  time 
in  order  to  estimate  the  total  capacity  of  the  pus-cavity,  and  obtain 
thereby  some  definite  information  as  to  the  degree  of  pulmonary  expan- 
sion. It  is  also  proper  to  irrigate  in  case  of  a  distinctly  fetid  odor  of 
the  pus,  although  fetor  in  itself  suggests  the  necessity  of  a  larger  opening 
and  of  more  complete  drainage,  rather  than  of  irrigation.  Unpleasant 
results  have  frequently  been  reported  from  the  use  of  irrigating  fluids. 
Such  possibility  may  be  avoided,  to  a  large  extent,  provided  certain  pre- 
cautions are  t^ken  concerning  the  method  of  irrigation.  A  normal 
salt  solution  or  one  of  boric  acid  is  the  best  fluid  for  this  purpose. 
The  use  of  solutions  of  mercury  bichlorid,  phenol,  and  similar  prepa- 
rations capable  of  undue  toxic  absorption  is  to  be  interdicted.  Owing 
to  the  admirable  drainage  usually  following  empyema  operations  the 
liability  of  toxic  absorption  froni  the  use  of  the  more  powerful  anti- 
septics is  indeed  slight,  but  disastrous  results  occasionally  follow  their 
use.  A  much  more  serious  accident  from  the  employment  of  irrigation 
is  the  occurrence  of  shock,  which  in  very  rare  instances  is  fatal.  At 
times  there  may  suddenly  develop  severe  nervous  manifestations, 
resulting  from  irritation  of  the  pleura.  Such  symptoms  as  syncope, 
convulsions,  hysteria,  epileptiform  attacks,  delirium,  monoplegia  and 
hemiplegia,  and  disturbances  of  vision,  though  exceedingly  rare,  never- 
theless may  occur  regartlless  of  the  nature  of  the  irrigating  fluid.  The 
avoidance  of  untoward  manifestations  accompanxdng  irrigation  may  be 
secured  in  most  cases  by  proper  attention  to  the  temperature  of  the  fluid 
and  to  the  manner  in  which  it  is  injected.  Extremes  of  heat  or  cold  are 
to  be  avoided,  a  temperature  of  about  100°  F.  being  the  most  desirable. 
The  solution  should  be  introduced  into  the  pleural  cavity  in  a  gentle, 
steady  flow. 

The  correct  application  of  the  dressings  after  pleurotomy  requires 
the  observance  of  strict  antiseptic  precautions.  The  demand  for  the 
most  scrupulous  care  in  this  respect  remains  continuously  and  rigidly 
in  force  until  the  final  closure  of  the  wound. 

An  adherence  to  these  principles  during  each  subsequent  dressing 
should  prevent  secondary  bacterial  contamination.  An  appropriate 
dre.ssing  may  also  be  of  material  assistance  in  favoring  the  expansion 
of  the  lung.  It  is  very  desirable  that  this  be  made  to  expand  as  quickly 
as  possible  and  to  the  fullest  extent.  Should  the  lung  become  bound 
down  by  the  formation  of  pleuritic  adhesions,  when  in  a  state  of  only 
partial  dilatation,  its  subsequent  expansion  is  rendered  extremely 
difficult,  if  not  impossible. 

By  reviewing  the  mechanic  principles  involved  in  the  process  of 
lung  expansion  it  becomes  apparent  that  one  function  of  the  dressing 
should  be  to  provide  for  the  ready  passage  of  the  air  jrom  the  pleural 
cavity,  and  to  obstruct,  as  far  as  possible,  its  reentrance. 

In  order  to  obtain  a  possible  valve-like  action  of  the  dressing  some 
surgeons  employ  external  to  a  thick  layer  of  aseptic  gauze  a  piece  of 
oiled  sUk  large  enough  in  size  to  project  upon  the  skin  in  every  direction, 
to  which  it  is  closely  applied  by  the  elastic  pressure  of  the  outer  dress- 
ings. 

WhUe  several  theories  have  been  presented  to  explain  the  expansion 


PNEUMOTHORAX  383 

of  the  lung  after  entrance  of  air  to  the  pleural  cavity,  their  elucidation 
involves  a  consideration  of  the  principles  of  dynamics,  which  does  not  fall 
within  the  scope  of  this  book. 

It  is  sufficient  to  show  that  at  least  one  element  among  the  several 
that  may  combine  to  promote  lung  expansion  is  the  application  of  an 
appropriate  dressing.  The  use  of  the  oiled  silk  or  muslin,  as  described, 
commends  itself  highly  in  theory.  It  may  be  properly  questioned, 
however,  if  a  generous  occlusive  aseptic  dressing  does  not  answer  quite 
as  well. 

In  the  after-treatment  systematic  "lung  gj-mnastics"  may  be  of 
considerable  service  in  aiding  the  expansion  of  the  previously  compressed 
lung.  The  use  of  the  James  method,  which  consists  of  the  transfer  of 
water  from  one  large  Wolff  bottle  to  another  by  means  of  the  expiratory 
effort  of  the  patient,  is  undoubtedly  of  some  service. 

The  expansion  of  lung  is  aided  to  a  considerable  extent  by  a  tem- 
porary residence  in  moderately  high  altitudes.  I  have  had  opportunity 
in  several  instances  to  note  the  excellent  results  obtained  among  cases 
sent  to  Colorado  for  this  purpose. 


CHAPTER   LV 

PNEUMOTHORAX 

Symptoms  and  Physical  Signs. — The  pathologic  conditions,  as 
well  as  the  syinptoiiis  :iiul  })h>sieal  signs,  are  found  to  differ  materially 
in  the  various  forms  of  pneumothorax.  In  like  manner  essential  tiiffer- 
ences  of  treatment  are  indicated  according  to  the  particular  type  of  the 
disease.  A  discussion  of  the  symptoms,  physical  signs,  diagnosis,  and 
treatment  of  this  somewhat  frequent  complication  of  consumption 
should  include,  therefore,  a  separate  consideration  of  the  open,  closed, 
and  valvular  varieties.  In  pneumothorax  among  tuberculous  cases 
the  entrance  of  air  into  the  pleural  cavity  is  effected  by  perforation 
of  the  visceral  pleura,  as  the  result  of  an  imderlying  pulmonary  cavity 
or  subpleural  caseous  focus.  Other  ways  in  which  air  may  enter  the 
pleural  cavity  are  of  rare  occurrence  among  pulmonary  invalids.  The 
symptoms  and  signs  are  directly  dependent  upon  the  changed  intra- 
thoracic relations,  which  vary  in  degree  according  to  the  antecedent 
pathologic  conditions.  Further,  the  clinical  manifestations  and  treat- 
ment are  modified  by  the  amount  of  air  present  in  the  pleural  cavity, 
and  by  certain  mechanic  conditions  influencing  the  degree  of  positive 
intrathoracic  pressure.  Thus  the  character  and  severity  of  the  symp- 
toms vary  according  as  the  air  passes  in  and  out  with  each  respiratory 
act,  remains  in  a  closed  chamber,  or,  through  a  valvular  action  at  the 
point  of  perforation,  is  pumped  into  the  cavity  with  each  inspiiation. 
In  ordinary  cases  of  complete  pneumothorax  occurring  without  previ- 
ous pleuritic  adhesions  the  cardiac  and  respiratory  embarrassment  is 
extreme  and  the  physical  signs  exceptionally  well  defined.  Among  pul- 
monary invalids,  however,  by  virtue  of  the  previous  anatomic  change 
in  the  pulmonary  and  pleural  tissues,  varying  amounts  of  air  may  enter 


384  COMPLICATIOXS 

the  pleural  ca\aty  and  produce  essential  differences  in  the  clinical 
picture. 

In  partial  or  circumscribed  pneumothorax  the  non-existence  of 
typical  symptoms  and  signs  frequently  leads  to  grievous  errors  in  diagno- 
sis. The  classic  symptoms  of  general  pneumothorax  are  of  sudden 
development,  consisting  of  excruciating  pain  in  the  side,  extreme  dysp- 
nea, cyanosis,  and  collapse.  In  addition  to  the  agonizing  pain  and  sense 
of  impending  suffocation  there  is  often  experienced  keen  mental  anguish, 
which  is  reflected  in  the  facial  expression,  the  features  being  pinched 
and  drawn.  The  tcininrature  in  such  cases  is  almost  always  subnormal 
at  first,  but  m:i\  i  i-r  Mil  xciuently.  The  pulse,  though  usually  regarded 
at  such  time.s  ;i>  \ti\  itcMe.  extremely  rapid,  and  thready  in  character, 
does  not  always  conform  to  this  description.  I  have  observed  several 
invalids  exhibiting  extreme  dyspnea,  yet  \\ith  the  pulse  but  slightly 
affected. 

Some  3-ears  ago  I  saw,  in  consultation,  at  the  request  of  Dr.  Sewall, 
a  case  of  complete  pneumothorax  in  which  all  the  symptoms  save 
the  slow  and  regular  pulse  suggested  immediate  dissolution.  The 
patient,  who  had  assumed  the  sitting  posture  in  bed.  was  supported 
upon  each  side  by  an  attendant  and  was  rocking  to  and  fro,  moaning 
and  screaming  as  much  as  his  labored  and  frequent  respirations  would 
permit.  There  were  pronounced  cyanosis  and  excessive  dyspnea.  A 
provisional  diagnosis  of  pneumothorax,  which  was  entertained  on  the 
score  of  the  abrupt  onset  and  urgent  symptoms,  was  verified  upon  exami- 
nation, and  the  patient  relieved  for  the  time  being  by  aspiration. 

The  development  of  pneumothorax  frequently  accompanies  unus- 
ually severe  spells  of  cough  or  sudden  exertion.  I  have  observed  its 
occurrence  several  times  in  connection  ^^^th  the  lifting  of  heavy  objects, 
and  in  two  instances  as  a  result  of  rising  upon  the  toes  and  stretching 
the  arm  to  reach  a  chandelier. 

In  contradistinction  to  the  sudden  terrifying  onset  with  pain,  mental 
anguish,  air-hunger,  and  varying  degrees  of  collapse  following  severe 
cough  or  other  obvious  cause,  pneumothorax  ?««//  develop  in  pitlmmmri/ 
invalids  and  be  entirely  devoid  of  clinical  symptoms  and  witliout  visible 
explanation.  The  absence  of  initial  symptoms  does  not  suggest  the 
necessity  of  physical  exploration,  and  the  condition  often  remains 
unsuspected  until  recn^iiizcil  at  tlie  time  of  a  subsequent  examination. 
I  have  discovered  instaiicis  m  imeumothorax  several  weeks  after  a  care- 
ful chest  examination,  nu  iutcnurring  symptoms  of  note  having  super- 
vened. In  a  few  cases  it  developed  without  symptoms  or  apparent 
cause,  the  patient  being  constantly  in  the  recumbent  position. 

A  case  in  point  is  that  of  a  male  patient,  whose  chest  was  examined 
with  negative  result  as  regards  pneumothorax  two  days  before  going  to 
bed  for  an  acute  tonsillitis.  One  week  later,  before  permitting  him  to 
arise,  the  lungs  were  examined,  and  a  well-defined  pneumothorax  was 
found.  A  patient,  shortly  before  a  pulmonary  hemorrhage,  disclosed 
not  the  slightest  evidence  of  an  existing  pneumothora.x,  but  several 
days  after  subsidence  of  the  bleeding  this  condition  \va.s  discovered. 
This  seems  all  the  more  remarkable  in  view  of  the  fact  that  morphin 
was  freely  administered  and  a  slow  respiration  rate  maintained  through- 
out the  illness.  This  case  was  especially  interesting  and  instructive 
because  of  the  previous  existence  of  fibrous  tissue  contraction  pulling 
the  heart  appreciably  to  the  left,  upon  which  side  the  pneumothorax 


PNEUMOTHORAX  385 

took  place.  There  resulted  the  anomalous  presence  of  a  wfll-defined 
pneumothorax  with  heart  displaced  toward  the  affected  side. 

An  important  feature  in  connection  with  the  clinical  manifestations 
of  pneumothorax  in  some  cases  is  the  mild  initial  disturbance,  with  a 
continuous  increase  in  severity,  even  to  the  point  of  suffocation  and 
death,  unless  relieved  by  aspiration.  This  sequence  of  urgent  symp- 
toms following  an  apparently  benign  onset  is  due  to  the  entrance  of  air 
through  a  perforation  of  minute  size,  with,  however,  a  progressive  gradual 
accumulation.  Upon  inspiration  but  a  slight  amount  of  air  is  admitted 
through  a  patulous  opening,  while  on  account  of  its  immediate  closure 
the  air  is  unable  to  escape  during  expiration.  The  symptoms  may  rapidly 
or  slowly  increase  in  severity  in  proportion  to  the  amount  of  air  enter- 
ing the  cavity  with  each  respiratory  act.  Whether  this  difference  in  the 
time  of  development  of  distressing  symptoms  is  due  entirely  to  the  size 
of  the  perforation  or  in  part  to  the  degree  of  valvular  competency  is 
difficult  to  determine.  Certain  it  is  that,  from  a  clinical  standpoint,  cases 
of  valvular  pneumothorax  exhibit  an  extreme  variation  in  the  onset 
of  desperate  symptoms,  as  well  as  in  their  recurrence  following  aspir- 
ation. It  has  been  my  experience  that  the  average  patient  develops  a 
sense  of  urgent  air-hunger  in  two  or  three  hours  after  the  immense 
relief  afforded  by  aspiration.  I  have,  however,  seen  invalids  lapse  into 
their  previous  impending  suffocation  before  the  expiration  of  one-half 
hour  subsequent  to  removal  of  the  air.  On  the  other  hand,  two  patients 
have  recently  been  observed  in  whom  the  entrance  of  air  with  each 
inspiration  was  so  slight  that  the  recurring  symptoms  were  delayed  for 
forty-eight  hours  after  the  aspiration. 

The  physical  signs  of  pneumothorax  in  pulmonary  invalids  must 
vary  within  wide  limits,  according  to  the  extent  of  the  condition  and  the 
peculiar  type  present  in  individual  cases.  It  should  not  be  imagined 
that  pneumothorax  must  invariably  exhibit  such  typical  signs  as  bulging 
of  the  rib-spaces,  complete  immobility  of  side,  resounding  tyiiipuuy, 
dislocation  of  organs,  and  amphoric  or  cavernous  respiiaticui.  Such  a 
group  of  physical  signs  should  be  understood  to  apply  solely  to  casts  of 
complete  pneumothorax.  In  such  cases  there  may  be  impaired  mobility 
of  the  affected  side,  which  is  compensated  for  by  an  exaggerated  excur- 
sion of  the  other.  Bulging  of  the  rib-spaces  is  by  no  means  constant, 
although  occasionally  present.  The  vocal  fremitus,  which  is  often 
described  as  much  diminished  or  absent  over  the  affected  side,  may 
even  be  somewhat  intensified  when  there  is  a  free  communication  with 
a  bronchial  tube.  In  closed  or  valvular  forms  of  pneumothorax,  how- 
ever, the  vocal  resonance  and  fremitus  are  diminished  very  considerably. 

The  percussion-note  varies  materially  in  accordance  with  the  form 
of  pneumothorax  and  the  quantity  of  contained  air.  In  the  open  variety 
the  resonance  is  usually  tympanitic  or  amplioric.  although  the  cracked- 
pot  sound  is  .sometimes  recognized,  as  well  as  Winl  rich's  change  of  pitch. 
In  cases  of  clo.sed  or  valvular  pneumothorax  the  tympanitic  reisonance 
is  usually  pronounced,  but  may  be  muffled  in  charactel',  and  the  pitch 
more  or  less  elevated.  An  excessive  hyperdistention  of  the  pleural  sac 
incident  to  the  contained  air  may  give  rise  to  marked  dulness  and  occa- 
sion an  error  of  diagnosis.  I  recollect  an  instructive  case,  seen  ten  years 
ago,  the  patient  coming  under  observation  some  two  weeks  following  an 
initial  pain  in  the  side,  with  gradually  increasing  shortness  of  breath. 
There  was  but  little  cough  or  expectoration.     The  fever  was  moderate, 


386  COMPLICATIONS 

and  dyspnea  well  marked.  Examination  of  the  chest  disclosed  pro- 
nounced dulness  of  the  entire  left  side,  front  and  back,  with  complete 
absence  of  respiratory  and  voice-sounds,  save  in  the  extreme  upper 
portion.  The  heart  was  dislocated  to  the  right.  The  extreme  dulness 
of  the  left  side,  in  conjunction  with  other  signs,  suggested  clearly  a 
chagnosis  of  large  pleural  effusion,  which  was  indorsed  by  two  con- 
sultants preliminary  to  aspiration.  The  conchtion,  however,  proved  to 
be  one  of  simple  valvular  pneumothorax.  It  is  important  to  emphasize, 
in  this  connection,  the  pos.^ibility  of  didness  upon  percussion  on  account 
of  the  extreme  tension  incident  to  intrathoracic  pressure. 

The  auscultatory  signs  are  also  subject  to  great  variation  in  different 
cases.  In  open  pneumothorax  the  respiration  is  usually  amphoric  or 
cavernous  in  character.  These  types  of  respiration  cannot  exist  unless 
the  air  passes  freely  in  and  out  of  the  pleural  ca\it}-  with  each  respiration. 
Under  such  conchtions  the  vocal  resonance  is  intensified,  as  in  pulmonary 
cavities.  Rales  are  sometimes  heard  which  possess  a  distinct  musical 
qualit}".  Metallic  tinkling  occurs  only  when  liquid  as  well  as  air  is 
present  in  the  pleural  cavity.  This  is  also  true  of  the  succussion  sign 
and  the  area  of  movable  flatness,  to  which  allusion  has  been  made. 

In  the  closed  or  valvular  forms  of  pneumothorax  the  breath-sounds 
may  be  suppressed  entirely  or  much  enfeebled,  together  with  the  vocal 
resonance  and  fremitus. 

The  coin  sign  is  of  especial  value  in  open  pneumothorax,  and  consists 
of  the  intensified  echo  transmitted  to  the  ear  of  the  examiner  from  the 
tapping  of  one  coin  upon  another  placed  upon  the  opposite  side  of  the 
chest. 

The  diagnosis  of  acute  pneumothorax,  simple  as  it  would  appear, 
is  nevertheless  attended  with  some  difficulty  in  many  cases.  A  complete 
exploration  of  the  chest  should  be  sufficient,  as  a  general  rule,  to  estab- 
lish an  accurate  chagnosis.  There  should  be  no  difficulty  encountered 
in  recognizing  the  condition  whenever  liquid,  as  well  as  air,  is  present  in 
the  pleural  cavity,  as  the  signs  of  pneumopyothorax  are  so  characteristic 
as  to  preclude  confusion  in  their  interpretation  by  an  experienced 
examiner.  The  signs  especially  iiatlmundnKinic  of  pneumopyothorax 
will  be  considered  in  connection  with  iluit  ((nidition. 

Cases  of  circumscribed  i)neuniiitli(iiax  are  not  always  susceptible 
of  eas}^  chfferentiation  from  pulmonary  cavities,  as  these  conditions 
possess  many  physical  signs  in  common.  Among  these  are  the  caver- 
nous and  amphoric  types  of  respiration,  although  the  latter  is  more 
common  in  pneumothorax.  The  cracked-pot  resonance  is  an  inconstant 
sign,  and  is  present  not  infrequently  in  other  conchtions.  In  pneumo- 
thorax there  is  often  immobility  of  the  side,  with  displacement  of  the 
apex-beat.  The  respiratory  sounds  and  the  vocal  resonance  and  frem- 
itus are  diminished,  both  in  circumscribed  pneumothorax  and  over 
large  pulmonary  cavities,  provided  there  is  no  opportunity  for  free 
entrance  and  exit  of  air.  If  tlierc  is  open  communication  with  a  bron- 
chial tube,  however,  there  nia\'  be  ikiKhI  in  either  conihtion  cavernous 
or  amphoric  breathing,  as  well  as  gurizliug  rales  and  pectoriloquy.  Pneu- 
mothorax rarely  occurs  in  the  extreme  upper  portion  of  the  chest,  while 
pulmoiuuy  cavities  may  exist  in  any  part  of  the  lung. 

The  prognosis  in  pulmonary  invalids  varies  according  to  the  general 
condition,  the  antececient  pathologic  change,  the  size  of  the  air-chamber, 
and  the  particular  variety  of  pneumothorax.      Provided  there  is  not 


PXEUMOTHOKAX  387 

an  immediate  fatal  termination,  the  outlook  for  the  patient  must  be 
considered  upon  the  basis  of  the  chronic  pneumothorax.  Patients 
surviving  the  first  few  hours,  or  possibly  a  day,  often  linger  for  several 
weeks  and  may  even  recover  in  some  instances.  The  prognosis  attend- 
ing a  closed  pneumothorax  is  unquestionably  the  most  favorable  of  the 
three  forms.  The  existence  of  this  variety  implies  a  previous  rupture 
of  the  ]:)lciii-a.  whirh  sul)Sc(|ucntlv  has  complotolv  cld.^ed.  I'])Oii  tlic  hasis 
of  the  pliNsiral  -1,-iis  alone  ii  is  soiiictiiiics  diiiicult  to  (list iu^ui^h  this 
from  tln'  \alviilaj-  type,  althou.^ij.  as  a.  nilc.  in  the  (■lo^(■(l  va.ni-t>-  there 
is  less  innnobility  of  the  side  ami  less  buluinu,  while  tlie  symptoms  are 
usually  not  urgent.  The  prognostic  inlhience  of  tliis  form  of  pneumo- 
thorax upon  pulmonary  tuberculosis  is  not  necessarily  unfavorable.  The 
chief  danger  lies  in  the  opiiortuiiity  alToi('e(|  for  secondar}^  infection 
through  the  entrance  of  niiiToor^anisms  betore  healing  of  the  perfora- 
tion. There  is  at  times  an  apparent  diminution  in  the  activity  of  the 
tuberculous  infection,  as  a  result  of  the  pulmonary  compression,  the 
expectoration  and  cough  often  being  materially  lessened.  If  the  pneumo- 
thorax is  not  complete,  there  is  but  slight  cardiac  or  respiratory  embar- 
rassment. Gain  in  weight  and  (Iisap)i(>arance  of  fever  sfimetimes  attend 
moderate  compression  of  Inni!.  in  man}-  cases  tiie  aii-  is  absorbed 
gradually,  after  which  an  advain'inii  exjiansion  of  the  lun,n  lalu'S  place. 

On  the  other  hand,  the  open  jjneumothorax,  in  the  majority  of  cases, 
is  transformed  without  delay  into  a  pneumopyothorax  bj'  the  entrance 
of  bacteria.  The  prognosis  of  these  cases  varies,  as  in  empj^ema,  accord- 
ing to  the  character  of  the  infection  and  the  resulting  influence  upon  the 
general  health.  In  addition  to  the  paroxysmal  cough,  with  copious 
morning  and  evening  expectoration,  symptoms  of  profound  systemic 
infection  may  supervene.  In  this  event  the  patient  exliibits  cliills  and 
sharp  daily  exacerbations  of  temperature,  and  in  many  instances  pro- 
fuse sweats.  The  future  of  these  consumptives  is  fraught  with  great 
danger,  but  the  condition  is  not  necessarily  fatal.  Some,  under  prompt 
surgical  manauement,  lin.-illy  achieve  recovery,  and  others  secure  a  pro- 
longed lease  of  lile.  althoHLih  succumbing  eventually. 

The  valvular  torm  of  |incrinoth()i'ax  is  the  least  favorable  of  all 
varieties.  Tlie  sympionis  are  extremely  urgent,  the  sufferings  severe, 
the  dyspnea  intense,  and  ilie  (la,n,!j;er  imminent.  The  immediate  outlook 
for  the  patient  is  largely  dependent  upon  tlie  character  of  therapeutic 
management.  Stimulation.  ;ilthou,i;ii  clearly  indic:ite(l,  is  of  but  trifling 
value  in  comparison  with  tlie  \asi  inipoitaine  attached  to  the  relief  of 
the  intrathoracic  distention  by  removal  of  the  contained  air.  Often  the 
respite  afforded  by  aspiration  is  of  but  a  few  hours'  duration,  and 
although  this  may  be  repeated  at  intervals,  the  patient  is  saved  merely 
from  an  initial  collapse.  A  certain  number  of  cases,  no  matter  how 
desperate  the  situation,  finally  recover  through  prompt  and  repeated 
aspiration  accompanied  by  heroic  stimulation.  An  eventual  disappear- 
ance of  the  pneumothorax  may  take  place  in  a  few  instances,  as  will  be 
shown  by  tlie  citation  of  an  illustrative  case.  At  best  the  prognosis  is 
exceedingly  grave. 

Treatment. — The  treatment  of  simple  pneumothorax  depends 
almost  entirely  upon  the  urgency  of  the  symptoms.  If  extreme,  the 
early  medicinal  treatment  con.sists  of  excessive  stimulation  and  the 
hypodermic  administration  of  morphin.  The  latter  is  often  of  the 
utmost  value,  and  in  many  ca.ses  transcends  in  importance  all  other 


dOO  COMPLICATIONS 

remedial  efforts.  A  quarter  of  a  grain  of  morphin  injected  subeutane- 
ously  will  often  mitigate  to  a  marked  extent  the  severity  of  the  symp- 
toms. As  cardiac  and  respiratory  stimulants,  str3-chnin  and  atropin  are 
recommended,  together  with  free  inhalations  of  oxygen.  The  urgency  of 
the  condition  in  acute  general  pneumothorax  represents  one  of  the  few 
occasions  when  oxygen  is  peculiarly  efficacious.  The  indications  for 
treatment  point  solely  to  general  measures,  as  morphin,  stimulation, 
and  oxygen.  In  open  cases  the  efforts  of  the  physician  must  be  con- 
fined to  the  relief  of  pain  and  general  stimulation,  imtil  opportunity 
has  been  afforded  for  the  adaptation  of  the  damaged  respiratory  appar- 
atus to  the  functional  needs  of  the  system. 

The  treatment  of  a  closed  pneimiothorax  should  relate  to  the  avoid- 
ance of  a  renewed  perforation,  which  would  expose  the  patient  to  the  dan- 
ger of  .secondary  infection.  Absolute  quiet  should  be  enjoined  for  a  con- 
siderable time,  lest  by  some  sudden  untoward  movement  ruptm-e  of  the 
pleura  may  result.  Cough  must  be  avoided  as  much  as  possible.  To 
this  end  opiates  are  sometimes  indicated  for  the  time  being,  to  meet  the 
requirements  of  individual  cases.  If  the  cough  is  especially  severe,  it 
is  good  practice  to  strap  the  chest  with  adhesive  plaster  in  order  to 
restrict,  as  much  as  possible,  the  movement  of  the  affected  side.  After 
several  weeks'  delay  it  may  be  permissible  to  withdraw  a  small  portion 
of  air  under  verj-  gentle  negative  pressiu-e.  This  procedure,  however, 
is  not  to  be  commended  in  general,  as  even  if  carefully  practised  it  may 
sometimes  result  in  reopening  the  visceral  pleura. 

In  acute  valvular  cases  relief,  as  a  rule,  is  seciu-ed  only  through  the 
performance  of  aspiration,  and  is  almost  instantaneous  with  the  with- 
drawal of  air.  This  is  imperatively  indicated  as  soon  as  the  symptoms 
become  at  all  lu-gent.  There  is  no  conventional  point  of  puncture  to 
be  recommentled.  The  essential  consideration  is  to  enter  the  air- 
chamber,  the  limits  of  which  are  determined  by  the  physical  signs.  The 
same  precautionary  measures  should  be  observed  as  with  aspiration 
of  the  fluid  in  pleural  effu.sions.  in  which  event  no  liad  results  attend 
repeated  withilrawal  of  the  air.  If  a  considerable  time  elapses  after 
aspiration  before  the  i-eappearance  of  dangei-ous  symptoms,  the  indica- 
tions point  to  its  repetition  rather  than  to  more  radical  measures.  It 
occasionally  happens  that  a  few  judiciously  interspaced  aspirations  are 
sufficient  to  sustain  life  during  the  period  of  extreme  urgency.  Cases 
exhibiting  a  .speedy  recurrence  of  alarming  symptoms  following  aspira- 
tion demand  a  free  opening  through  the  chest -wall  into  the  pleural 
cavity.  I  do  not  hesitate  in  such  cases  to  insert  a  large-sized  trocar  and 
cannula.  The  trocar  is  withdrawn  and  the  cannula  is  fastened  to  the 
chest-wall  by  plaster,  and  covered  lightly  with  an  aseptic  dressing,  which 
is  frequently  changed.  This  method  of  treatment  is  attended  by  a 
pronounced  egress  of  air  from  the  chest  with  each  expiration,  and  in 
man}'  cases  is  instrumental  in  affording  relief  from  most  distressing 
symptoms.  It  is  the  treatment  par  excellence  for  desperate  cases,  and 
will  occasionally  enable  the  invalid  to  secure  an  adaptation  to  the  radi- 
cally changed  respiratory  condition.  .At  this  time  tlie  free  use  of  oxy- 
gen as  in  initial  open  pneumothorax  is  of  substantial  aid. 

In  connection  with  the  preceding  principles  of  treatment  applicable 
to  extreme  conditions  the  following  case  is  of  especial  interest,  and  also 
illustrates  the  not  infrequent  slowness  of  onset. 

In  the  summer  of  1905  a  young  man  with  advanced  pulmonary 


PNEUMOPYOTHORAX  389 

tuberculosis  was  sojourning  with  his  parents  in  the  mountains  of  Colo- 
rado, at  a  point  far  removed  from  railroad  communication.  After 
several  days  of  indisposition,  shortness  of  breath  was  noted,  together 
with  moderate  pain  in  the  left  side  and  conspicuous  aggravation  of 
cough.  This  was  frequent,  distressing,  markedly  paroxysmal,  and 
unattended  by  expectoration.  The  transition  fi-om  an  amiable,  gentle 
disposition  to  extreme  irritability  was  a  uolicculjlr  feature.  Dy.spnea, 
pain,  and  the  nervous  disturbance  pro,nr('ssi\'cly  increased  during  the 
next  few  days.  In  response  to  an  urgent  sunuiious  I  found  the  patient 
after  the  lapse  of  nearly  twelve  hours  in  extremis  by  rea.son  of  a  per- 
fectly defined  valvular  pneumothorax.  The  relief  afforded  by  aspiration 
was  almost  instantaneous,  but  this  was  again  required  after  twelve 
hours.  Aspiration  was  employed  at  intervals  of  four  or  five  hours 
during  the  ensumg  two  days,  and  afforded  in  each  instance  a  great 
measure  of  relief.  The  patient,  however,  became  much  exhausted  from 
the  frequent  recurrence  of  positive  intrathoracic  air-pressiu'e,  and  his 
sufferings  were  almost  beyond  endurance.  The  nervous  control  was 
entirely  lost,  and  the  condition  became  almost  maniacal.  During  a 
period  of  two  hours  the  pvilse  entirely  disappeared,  the  skin  being  bathed 
with  cold  perspiration.  Cyanosis  was  intense,  and  death  was  imminent. 
Against  the  protests  of  the  parents,  who  demanded  that  his  sufferings 
should  be  permitted  to  cease,  I  resorted  to  an  unusual  degree  of  stimu- 
ulation  with  strychnin,  atropin,  and  subcutaneous  salt  solution  and 
made  a  free  opening  into  the  pleural  cavity.  A  lai'ge  trocar  and  can- 
nula were  inscrtcil  bclwccii  the  Ihinl  Mid  louitli  lilis  in  the  anterior 
axillary  lino,  'i'hc  tiocui'  \\:is  icnidved.  and  :i  iii;li1.  Idcim^  aseptic  dre.s.sing 
applied  over  the  cannula.  The  e.\it  of  air,  which  was  attended  by  a  loud 
hissing  noise,  afforded  immediate  relief.  The  cannula  remained  in  place 
for  three  days,  during  which  time  a  perceptible  improvement  was  noted 
in  the  general  condition,  the  respirations,  and  pulse.  It  was  then 
removed,  but  replaced  upon  the  following  day,  on  account  of  the  renewed 
development  of  dyspnea  and  cyanosis.  After  several  days  the  cannula 
was  again  removed  without  a  subsequent  reappearance  of  urgent  symp- 
toms. A  week  later  a  small  amount  of  air  was  removed  by  gentle  aspir- 
ation, care  being  taken  to  avoid  too  great  a  negative  pressure  within  the 
pleural  cavity.  This  was  repeated  several  times  at  intervals  of  one  or 
two  weeks.  The  patient  greatly  improved  in  his  general  condition,  and 
at  the  end  of  three  months  it  was  impossilile  to  detect  upon  rigid 
physical  examination  the  .slightest  evidence  of  pneumothorax.  I  have 
refrained  from  devoting  space  to  the  enumeration  of  the  physical  signs 
in  this  case,  as  they  conformed  closely  to  the  type  described  as  charac- 
teristic of  such  cases. 


CHAPTER   LVI 
PNEUMOPYOTHORAX 

Physical  Signs. — When,  in  addition  to  tlie  air,  liquid  is  also 
present  in  the  pleural  cavity,  the  symptoms  common  to  simple  pneumo- 
thorax are  considerably  modified.  The  more  important  differences  in 
the  clinical  manifestations  relate  to  the  varying  degrees  of  .systemic 


390  COMPLICATIONS 

disturbance.  The  presence  of  pus  in  the  pleural  cavity  often  gives  rise 
to  the  exhibition  of  chills,  fever,  sweats,  and  digestive  disorders.  This 
group  of  sj'mptoms,  though  not  invariably  present  in  pneumopyothorax, 
are  more  frequent  than  in  the  preceding  concUtion.  The  appetite  is 
often  impaired,  and  gastric  cUsturbance  with  constipation  is  common. 
Edema  of  the  face  may  be  noticeable,  together  with  slight  cyanosis. 
There  is  frequently  imparted  a  slight  c}-anotic  cUscoIoration  to  the  face, 
which  in  association  with  pallor  and  edema  produces  a  rather  character- 
istic appearance.  The  ends  of  the  fingers  are  usually  thickened,  both 
laterally  and  anteroposteriorly,  and  present  a  peculiar  clubbed  shape. 
The  cough  is  apt  to  be  paroxysmal  and  associated  with  the  periodic 
expectoration  of  large  quantities  of  purulent  sputum.  This  is  especially 
noticeable  in  the  morning  and  evening,  as  well  as  upon  stooping  over 
or  l3'ing  down  during  the  daj*.  These  patients  usually  sleep  upon  the 
back,  though  sometimes  upon  the  affected  side.  Turning  to  the  oppo- 
site side  may  be  accompanied  by  the  expulsion  of  considerable  expec- 
toration. When  the  condition  is  essentially  a  chronic  process,  in  the 
absence  of  systemic  infection  there  may  be  lacking  any  rational  symp- 
toms to  suggest  its  presence. 

The  physical  signs,  however,  are  strikingly  characteristic,  although 
frequently  unrecognized.  While  the  presence  of  air  is  often  detectetl 
upon  examination,  the  liquid,  if  occurring  only  in  moderate  amount, 
is  not  infrequently  overlooked.  In  pneumopyothorax  the  upper  level 
of  the  fluid  conforms  strictly  to  a  horizontal  plane,  and  being  contained 
at  the  extreme  base  of  the  thorax,  may  escape  notice  if  a  careful 
physical  investigation  is  not  made  at  this  point.  By  comparing  the 
lower  boundaries  of  percussion  resonance  on  the  two  sides  there  should 
be  no  difficulty  in  recognizing  an  area  of  flatness.  The  disparity  between 
these  corresponding  regions  upon  percussion  is  emphasized  b}-  the  usual 
development  of  emphysema  upon  the  opposite  side,  still  further  lower- 
ing its  resonant  border.  In  contradistinction  to  the  curved  line  of 
dulness  incident  to  pleural  effusions  the  upper  boundary  of  percussion 
flatness  in  pneumopyothorax  is  always  pcrfectlfi  straight  and  horizontal. 
A  striking  corroborative  percussion  sign  is  the  marked  variation  in  the 
level  of  flatness,  with  a  corresponding  change  in  the  position  of  the 
patient.  The  presence  of  air  and  liquid  combined  in  the  pleural  cavity 
is  the  only  condition  permitting  a  pronounced  change  in  the  upper  level 
of  percussion  flatness.  This  is  a  physical  sign  of  the  utmost  impor- 
tance, and  may  be  regarded  as  cUstinctly  pathognomonic  of  pneumo- 
pyothorax. 

The  auscultatory  signs  are  not  appreciably  different  from  those  of 
simple  pneumothorax,  save  that  the  breath-  and  ^'oice-sounds  are  dimin- 
ished or  absent  below  the  level  of  the  liquid.  Metallic  tinkling,  as  pre- 
viously described,  may  be  recognized,  antl  is  strongly  suggestive  of 
pneumopyothorax,  although  occasionally  heard  in  the  presence  of  large 
pulmonary  cavities  containing  liquid.  A  feature  of  great  import  is  the 
succussion  splash  elicited  by  shaking  the  body  quickly  with  one  ear  in 
direct  apposition  to  the  chest. 

The  treatment  of  pneumopyothorax  among  consumptives  in  the 
absence  of  well-defined  septic  manifestations  consists  of  a  rigid  adher- 
ence to  the  "  laissez  faire' '  policy.  Sometimes  the  indications  point 
to  the  removal  of  the  fluid  by  reason  of  its  mechanic  effect  and  the 
degree  of  septic  absorption.    Occasional  aspiration  is  the  most  conserva- 


PNEUMOPYOTHORAX  •  391 

tive  means  of  emptying  the  cavity,  and  in  some  cases  this  measure  is 
all  that  is  required.  Excellent  results  may  attend  the  employment  of 
siphon  drainage.  A  trocar  with  cannula  is  inserted  between  the  ribs, 
the  trocar  removed,  and  a  tightly  fitting  rubber  tube  inserted  through 
the  cannula.  This  is  subsequently  withdrawn  over  the  tube,  which  is 
left  protruding  into  the  pleural  cavity.  The  other  end  of  the  tube  is 
passed  through  the  cork  of  a  bottle,  which  may  be  carried  in  the  pocket 
and  emptied  at  intervals  during  the  day.  The  flow  is  controlled  by 
clamps  upon  the  tube.  1  have  known  of  several  cases  in  which  this 
procedure  has  produced  highly  satisfactory  results.  If  this  expedient 
is  found  impracticable,  or  insufficient  on  account  of  the  existence  of 
urgent  symptoms,  recourse  must  be  taken  to  an  operation  which,  to 
this  class  of  cases,  is  often  of  direful  import,  i.  e.,  the  permanent  opening 
of  the  pleural  cavity.  From  my  observation  it  would  almost  seem  that 
for  these  unfortunates  the  classic  inscription  of  Dante  should  be  changed 
to  "Abandon  hope  all  ye  who  are  entei-ed  here."  The  thoroughly 
collapsed  and  atelectatic  lung  is  usually  bound  down  by  firm  adhesions, 
precluding  all  prospect  of  its  ever  expanding  without  removal  of  the 
visceral  pleura,  and  even  then  to  a  limited  extent.  There  begins  at 
once  the  period  of  interminable  suppuration  and  drainage,  the  none 
too  cheerful  prospect  of  repeated  rib  resections,  after  the  manner  of 
Estlander  or  Schede,  decortication  of  lung,  as  introduced  by  Delorme 
and  Fowler,  or  discission  of  pleura,  as  devised  and  practised  by 
Ransohoff.  The  shock  attending  these  major  operations,  the  subse- 
quent suitViiiLu,  tlie  disaiipointment  incident  to  non-healing  wounds, 
the  iucN  itaiilc  exhaustion,  and  the  frequent  amyloid  change  jointly  con- 
stitute rdUMilcratious  of  sufficient  import  to  furnish  grounds  for  reason- 
able hesitation  in  advising  these  mutilative  procedures.  Judging  solely 
from  a  considerable  experience  with  these  cases,  the  conclusion  is  reached 
that  the  results  at  best  are  likely  to  be  unsatisfactory,  although  in  some 
instances  a  prolonged  respite  is  offered  to  the  unfortunate  consumptive. 
Perhaps  a  few  years  of  this  existence  is  preferable  to  an  earlier  death, 
and  affords  a  justification  for  the  operation  in  selected  cases. 

The  dictum  laid  down  by  some  authors  that  pyopneumothorax 
developing  among  consumptives,  regardless  of  other  considerations,  con- 
traindicates  the  adoption  of  radical  measures  is  unquestionably  errone- 
ous. In  the  presence  of  sepsis,  chills,  fever,  and  sweating,  the  indications 
for  immediate  removal  of  the  pus  by  means  of  a  permanent  opening 
into  the  pleural  cavity  are  equally  imperative  as  with  the  non-tubercu- 
lous. No  matter  how  great  the  cxticniit y.  the  pulmonary  invalid  is 
entitled  to  the  same  prompt  mcasuirs  u(  idicf  as  the  non-consumptive. 
It  must  be  admitted,  however,  that  tlic  cdutlition  of  the  patient  is  a 
strong  determining  factor  in  a  choice  of  the  precise  method  of  surgical 
interference.  Even  in  highly  desperate  conditions  with  extreme  phy- 
sical debility  and  pronounced  evidence  of  sepsis,  aspiration  alone  is 
scarcely  ever  sufficient.  In  such  ca.ses  thoracotomy  is  more  efficacious 
as  a  means  of  prolonging  life  and  promotmg  recovery,  and  also  is  quite 
as  easily  performed  even  without  the  employment  of  anesthesia.  The 
operation  consists  of  the  introduction  of  a  large  trocar  and  cannula 
into  the  chest- wall,  followed  by  the  removal  of  the  trocar  and  the 
retention  of  either  the  cannula  or  of  a  short  rubber  tube  over  which 
the  cannula  is  withdrawn.  Care  should  be  taken  that  the  end  of  the 
tube  is  not  inserted  too  far  within  the  pleural  cavity.     Continued  drain- 


392  COMPLICATIONS 

age  by  this  method  is  usually  unsatisfactory,  as  the  narrow  rib-spaces 
prevent  more  than  a  small  opening.  The  tube  is  very  likely  to  become 
occluded  by  obstructive  coagula  of  pus,  blood,  or  lymph.  When, 
therefore,  the  prompt  removal  of  pus  is  demanded  in  profoundly  septic 
cases,  single  rib  resection  should  be  performetl  no  matter  how  desperate 
the  condition.  This  procedure  conserves  the  interests  of  the  patient, 
both  as  regards  the  immediate  present  and  the  not  too  remote  future. 
All  cases  permitting  the  administration  of  an  anesthetic  should  be  sub- 
jected to  single  rib  resection  in  preference  to  aspiration  or  puncture, 
but  the  inadvisability  of  an  anesthetic  should  not  always  be  con- 
strued as  an  argument  against  the  more  radical  operation.  This  may 
be  performed  by  a  skilful  surgeon  in  an  exceetlingly  short  time  without 
general  anesthesia,  as  I  have  been  permitted  to  observe  upon  repeated 
occasions.  In  desperate  cases  thorough  preliminary  cocainization  of 
the  .soft  parts  renders  the  incision  down  to  the  rib  perfectlj-  painless. 
After  denudation  of  the  periosteum  the  rib  may  be  quickly  resected, 
either  without  anesthetic  or  with  the  patient  under  the  influence  of 
somnoform.  By  the  use  of  this  anesthetic  Dr.  Powers  has  recently 
resected  the  rib  of  one  of  my  patients  who  was  apparently  moribund. 
The  preliminary  incision  was  rendered  painless  by  the  use  of  cocain, 
while  the  entire  period  of  somnoform  anesthesia  was  less  than  half  a 
minute.  Before  the  discovery  of  somnoform  I  performed  rib  resection 
with  cocain  in  a  very  extreme  case  unsuited  for  general  anesthesia. 
The  operation  was  undertaken  twelve  years  ago,  when  the  contlition  of 
the  patient  was  such  as  almost  to  demand  non-interference.  His  sub- 
sequent general  improvement  was  remarkable  until  the  development 
of  amyloid  after  several  years.  Multiple  rib  resection,  decortication 
of  lung,  and  discission  of  pleura  are  permissible  only  in  selected  cases, 
months  after  the  preliminary  opening  into  the  pleural  cavity.  It  is  of 
the  utmost  importance  that  such  operations  be  deferred  until  long  after 
the  initial  evacuation  of  pus.  The  condition  of  the  patient  is  usually 
such  at  the  time  of  the  initial  rib  resection  as  to  render  the  case 
inoperable  as  regards  the  major  operations.  With  the  removal  of  pus 
and  the  maintenance  of  continuous  drainage  an  entire  disappearance  of 
systemic  infection  often  takes  place.  Opportunity  is  thus  afforded  for 
gain  in  strength  and,  above  all,  in  nutrition,  the  value  of  which  in  such 
cases  cannot  be  overestimated.  After  a  dela.v  of  several  months  the 
patient  is  enabled  to  imdergo  the  shock  of  a  severer  operation.  Radical 
surgical  interference,  which  may  be  unworthy  of  consideration  at  the 
time  of  the  initial  pus  evacuation,  may  be  attended  by  marked  benefit 
six  months  later. 

I  recall  the  case  of  a  patient  with  pneumopj^othorax  upon  whom, 
at  my  request,  Dr.  Powers  performed  a  single  rib  resection  fovu-  years 
ago,  and  who  almost  succumbed  from  the  effects  of  the  preliminary 
operation.  The  capacity  of  the  pleural  cavity  shortly  after  the  opera- 
tion, as  determined  by  the  introduction  of  normal  salt  solution,  was 
64  ounces.  In  spite  of  perfect  drainage  and  daily  irrigation  a  persisting 
temperature  of  septic  t.vpe  was  observed  during  a  period  of  five  months. 
The  infection  was  distinctly  staphylococcic  in  character,  and  was  a.s.so- 
ciated  with  a  profound  purpura  ha^morrhagica.  Hemorrhages  took 
place  from  the  mouth,  no.se,  throat,  gums,  and  intestines,  with  the  for- 
mation of  petechia  under  the  skin.  About  two  months  following  the  first 
operation,  in  the  midst  of  an  exceedingly  poor  general  condition,  a  large 


PNEUMOPYOTHORAX  393 

counteropening  was  made  in  the  chest-wall.  Despite  perfect  drainage, 
secured  by  the  daily  passing  of  sterile  gauze  from  one  opening  to  the  other, 
there  ensued  no  resulting  improvement.  During  the  following  three 
months  there  occurred  morning  remissions,  with  sluup  evening  exacerba- 
tions of  temperature,  with  daily  chills  and  sweats.  Tliere  was  marked 
emaciation,  with  weak  and  extremely  rapid  i)ulse.  At  this  time  I  decided 
to  substitute  iodoform  gauze  for  that  previously  used.  This  was  drawn 
from  one  opening  to  the  other  and  the  jileural  cavity  freely  packed.  The 
temperature  receded  to  normal  upon  the  .second  day,  and  remained  so  for 
ten  days.  In  order  to  avoid  any  misconception  as  to  the  effort  of  the  ioflo- 
form,  I  reverted  once  more  to  the  use  of  the  sterile  gauze.  This  was  fol- 
lowed by  an  immediate  elevation  of  temperature,  whicli  persisted  several 
days  and  receded  at  once  upon  a  return  to  the  iodoform  pack.  It  is,  of 
course,  recognized  that  a  single  case  of  this  kind  must  not  be  accepted  as 
establishing  a  direct  relation  of  cause  and  effect,  as  regards  the  employ- 
ment of  the  iodoform  pack.     Improvement  was  progressive  and  rapid 


from  this  time.  Nine  months  after  the  rib  resection  the  patient,  having 
gained  thirty-five  pounds  in  weight,  a  Schede  operation  was  performed 
by  Dr.  Powers,  which  reduced  the  capacity  of  the  pleural  cavity  to  four 
ounces.  The  patient  is  now  in  excellent  condition,  the  discharge  being 
almost  nil  and  the  cavity  holding  but  one  and  one-half  ounces  of  salt 
solution.  Figs.  107,  108.  and  109  are  of  interest  in  showing  the  amount 
of  deformity  resulting  from  the  multiple  rib  resection  to  effect  an  oliliter- 
ation  of  the  pus-secreting  cavity.  This  would  have  been  completely  out 
of  the  question  as  an  early  operation. 

The  extent  of  the  operation  must  depend  largely  upon  the  size  of  the 
cavity  and  the  age  of  the  patient.  The  operation  is  rarely  demanded 
in  children  on  account  of  the  greater  elasticity  of  the  thorax.  Among 
adults,  however,  the  rigidity  of  the  chest-wall  presents  an  insuperable 
obstacle  to  the  obliteration  of  the  suppurating  space,  and  in  the  absence 
of  lung  expansion  the  resection  of  ribs  becomes  the  only  rational  pro- 
cedure.    The  removal  of  a  large  portion  of  the  bony  thorax  permits  the 


COMPLK  ATIOXS 


apposition  and   cicatrization  of  granulating  surfaces.      It  is  scarcely 
pertinent  to  the  purpose  of  this  book  to  enter  into  a  discussion  of  the 


Fig.  108.— Same  pat 


comparative  merits  of  the  Estlander  or  the  Schede   operation,   or  to 
attempt  a  description  of  the  technic. 

Decortication  of  the  lung,  as  introduced  by  Delorme.  consists  of  the 
removal  of  tho  viscoi:!'  |ilf'-'  from  the  lower  half  of  the  collapsed  and 


Fig.  109.— Photograph  of 


atelectatic  lung,  which  permits,  to  a  very  considerable  extent,  its  sub- 
sequent expansion.     This  operation  has  been  found  to  be  much  safer 


TUBERCULOSIS    OF    THE    PERICARDIUM  395 

and  more  easily  performed  than  the  attempted  removal  of  adhesions 
between  the  costal  and  visceral  pleura.  The  operation  is  sometimes 
practised  in  connection  with  Sehede's  multiple  rib  resection,  in  which 
event  the  skin-flap  coalesces  and  cicatrizes  with  the  denuded  lung.  In 
other  cases  a  trap-door  operation  is  performed,  which  includes  the  lifting 
of  a  portion  of  the  chest- wall,  permitting  free  access  to  the  collapsed 
lung  and  the  denudation  of  its  pleura.  Subsequently  the  trap-door  is 
replaced  and  provision  made  for  adequate  drainage. 

Discission  of  the  pleura  was  devised  and  performed  by  Ransohoff, 
and  has  yielded  fairly  satisfactory  result.s.  This  procedure  consists  of 
free  incisions  of  the  pleura  carried  downward  to  the  lung  proper. 


SECTION    III 
Tuberculosis  of  the  Pericardium  and  Peritoneum 


CHAPTER  LVII 
TUBERCULOSIS  OF  THE  PERICARDIUM 

Etiologic  and  Pathologic  Data. — This  condition,  on  account  of  its 
relative  infrequency,  is  of  much  less  importance  than  tulierculosis  of 
the  pleura  or  peritoneum.  It  is,  however,  considerably  more  common 
than  generally  supposed.  The  clinical  evidences  of  tuberculous  involve- 
ment of  the  pericardium  are  exceedingly  obscure. 

The  position  and  size  of  the  heart  may  be  outlined  with  reasonable 
accuracy  during  life  by  a  skilful  examiner,  and  the  results  confirmed  or 
modified  by  .r-v:iy  cxumination,  but  the  only  reliable  data  as  to  the  fre- 
quency and  natiii'c  of  the  pericardial  complications  in  pulmonary  tuber- 
culosis are  furnished  by  autopsy  findings.  To  be  of  definite  value  it  is 
obvious  that  the  postmortem  study  should  be  conducted  by  a  trained 
pathologist,  and  embrace  a  large  number  of  autopsies  upon  tuberculous 
subjects.  Only  by  means  of  such  investigations  are  there  afforded  cor- 
rect conceptions  as  to  the  prevalence  of  the  condition. 

During  the  first  two  years  of  the  existence  of  the  Phipps  Institute 
for  the  Study  of  Tuberculosis  there  were  conducted  143  autopsies,  88  of 
which  were  performed  in  the  first  year.  Of  the  88  autopsies,  there  was 
but  1  case  of  typical  miliary  tuberculosis  with  pericardial  involvement. 
There  were,  however,  3  cases  out  of  the  143  autopsies  during  the  two 
years.  Of  the  total  numlaer,  there  were  reported  3  cases  of  local  peri- 
cardial adhesions,  1  instance  of  general  pericardial  adhesion,  1  of  thick- 
ened  pericardium,  and  8  of  total  obliteration  of  the  pericardium.  Only 
1  case  of  acute  serous  pericarditis  was  found.  Evidence  of  peiicardial 
involvement  of  some  kind  was  obtained  in  18  cases  out  of  143,  including 
both  acute  and  chronic  varieties.  Actual  tubercles  were  found  in  only  3 
instances,  and  it  is,  therefore,  more  or  less  problematic  whether  or  not  the 
other  cases  were  of  actual  tuberculous  origin.     It  must  remain  a  matter 


39b  COMPLICATIONS 

of  conjecture  if  the  cases  of  chronic  obliterative  pericarditis  and  those 
with  local  adhesions  were  directly  occasioned  by  tuberculous  infection. 
It  is  reasonable  to  believe,  however,  that  nearly  all  low-grade  chronic 
inflammations  of  the  pericardium  among  pulmonary  invalids  owe  their 
existence  to  tubercle  deposit.  If  the  tuberculous  character  of  nearly  all 
idiopathic  pleurisies  is  admitted,  even  among  apparently  non-tubercu- 
lous subjects,  it  is  safe  to  assume  that  a  similar  involvement  of  the 
pericardium  may  occasionally  take  place  among  phthisical  patients. 

The  autopsy  report  with  study  of  heart  lesions  at  the  Phijips  Institute 
was  made  by  Drs.  White  and  Norris. 

In  the  third  annual  report,  recently  issued,  there  is  contained  a 
record  of  57  autopsies  conducted  during  the  past  year  upon  phthisical 
patients,  with  practically  negative  pericardial  findings.  Thus,  out  of 
200  autopsies  reported  in  three  years,  but  3  cases  of  miliary  involvement 
of  the  pericardium  were  found,  and  8,  or  4  per  cent.,  of  o])literative  peri- 
carditis. During  the  first  year  White  reports  the  latter  concUtion  in 
3.4  per  cent,  of  the  cases  recorded,  and  submits  for  comparison  oblit- 
erative pleurisy  of  both  sides  in  4.5  per  cent,  of  cases — the  left  side, 
19.5  per  cent.,  and  the  right  in  17  per  cent.  Of  the  pericardial  cases, 
one  coexisted  with  obliterative  pleurisy  upon  each  side,  one  with  right- 
sided  pleurisy,  and  one  with  general  adhesions  on  both  sides.  No  histo- 
logic investigation  was  macle  to  determine  precisely  the  tuberculous 
origin  of  the  adhesions.  Norris,  in  1904,  collected  statistics  concerning 
pericardial  involvement  in  1780  autop.sies  upon  tuberculous  subjects, 
and,  exclusive  of  doubtful  cases,  found  pericarditis,  which  w^as  presum- 
ably tuberculous,  to  have  occau-red  in  4.6  per  cent. 

Although  the  pericardium  occupif>^  a  more  or  less  protected  position 
as  far  as  opportunity  for  secdiulai y  infection  is  concerned,  it  is  not  sui-- 
prising  that  tuberculous  iii\(il\iMiiciit  should  supervene  on  account  of 
the  existence  of  tuberculous  proccs.ses  in  adjacent  structvu-es.  The 
condition  may  originate  from  neighboring  foci  of  infection  in  the  pleura, 
lungs,  mediastinal  glands,  and  from  caries  of  some  part  of  the  bony 
intrathoracic  wall,  notably  the  stermmi.  ribs,  and  dorsal  vertebra. 

In  a  large  number  of  cases  the  symptoms  of  tuberculous  pericarditis 
are  entirely  latent  during  life.  At  times  there  are  present  the  usual 
manifestations  of  general  miliary  tuberculosis,  without  distinct  evidence 
of  pericardial  involvement.  It  may  exi.st  clinically  as  the  ordinary 
acute  form  of  pericarditis,  either  of  the  dry  variety  or  accompanied  by 
effusion.  Another  group  of  cases  may  be  expected  to  exhibit  the  symp- 
toms of  functional  incapacity  a.ssociated  with  dilatation  and  hyper- 
trophy, which  result  in  many  instances  from  the  existence  of  chronic 
pericardial  adhesions.  The  two  latter  varieties  are  of  especuil  interest, 
one  pertaining  solely  to  an  acute  pericardial  coiidition,  and  the  other 
relating  to  adherent  pericardium,  with  possible  cliaiiiics  in  the  size  and 
position  of  the  heart  and  accompanj'ing  circulatory  di.stuibance. 

Varieties. — Acute  tuberculous  pericarchtis  which  is  likely  to  be 
overlooked  clinically  may  exist  in  two  forms — the  dry  plastic  variety 
and  the  type  characterized  by  effusion.  The  exudate  may  be  serous, 
.serofibrinous,  purulent,  or  hemorrhagic.  The  more  common  form  is  the 
plastic  pericarditis,  which  may  be  unattended  either  by  subjective 
symptoms  or  physical  signs.  The  serous  membrane  may  present  but 
a  dull,  slightly  roughened  appearance,  or  a  shaggy,  irregular  fibrinous 
coating.     The  fibrinous  exudation  upon  the  internal  pericardium  varies 


TUBERCULOSIS    OF    THE    PERICARDIUM  397 

much  in  thickness,  and  successive  layers  of  lymph  sometimes  completely 
cover  the  macroscopic  evidences  of  tubercle  deposit.  The  thickened 
membrane  may  be  infiltrated  with  tiny  yellowish-gra}'  tubercles,  or 
granulations  may  exist  between  the  layers  which  later  become  confluent. 
Upon  gross  inspection  there  is  often  no  evidence  of  tubercle  deposit, 
but  the  tuberculous  character  of  the  process  may  be  readily  demon- 
strable, despite  a  normal  macroscopic  appearance. 

Sjrmptoms. — The  only  subjective  symptom  of  the  acute  plastic 
form  of  tuberculous  pericarditis  is  pain,  ancl  this  is  not  always  present. 
It  is  rarely  intense,  although  in  exceptional  instances  quite  distressing. 
The  pain  is  usually  referred  either  to  the  precordial  region  or  to  the  tip 
of  the  ensiform  appendix.  It  is  sometimes  sharp  or  stabbing,  and 
occasionally  synchronous  with  the  cardiac  pulsation.  But  little  sig- 
nificance  is  to  be  attached  to  the  presence  of  fever  unless  this  develops 
in  conjunction  with  pain  and  objective  signs. 

Upon  palpation  there  is  sometimes  recognized,  synchronous  with  the 
heart  contractions,  an  appreciable  fremitus  to  the  left  of  the  sternum 
between  the  third  and  fourth  ribs.  The  important  auscultatory  sign 
is  the  to-and-fro  friction-sound.  This  may  be  creaking,  grazing,  rul)- 
bing,  or  grating  in  character.  It  is  more  frequently  a  rub,  and  gives  the 
impression  of  coming  from  directly  under  the  stethoscope.  These  super- 
ficial sounds  are  usually  intensified  by  increased  pressure  upon  the  skin 
with  the  bell  of  the  instrument.  They  may  be  heard  at  the  base,  but 
the  more  frequent  site  is  over  the  right  ventricle.  A  peculiar  feature  of 
the  friction-sounds  is  their  inconstancy,  as  they  are  often  recognized  at 
one  time  and  not  at  another.  They  are  distinguished  from  tlie  pleuro- 
pericardial  friction-rub  by  the  difference  in  rhythm  ami  the  influence 
of  the  respiratory  movement.  There  is  but  little  difficulty  in  differ- 
entiating the  distinct  rubbing  character  of  the  pericardial  sounds  from 
the  soft  blowing  endocardial  murmurs.  This  form  of  tuberculous  peri- 
carditis may  terminate  in  effusion,  or  the  contlition  may  be  changed 
into  that  of  adherent  pericardium,  owing  to  the  fusion  of  the  serous 
surfaces  through  connective-tissue  proliferation. 

The  symptoms  of  tuberculous  pericarditis  with  effusion  are  extremely 
variable,  and,  as  a  rule,  are  unposses,sed  of  special  significance.  In 
many  cases  they  are  entirely  absent  for  prolonged  periods,  and  the  con- 
dition escapes  recognition  altogether.  At  other  times  the  diagnosis  is 
made  purely  through  recourse  to  the  objective  signs.  It  is  not  unusual 
for  symptoms  previously  latent,  suddenly  to  assume  an  aggravated 
character.  Marked  dyspnea,  pain,  pallor,  or  cyanosis  may  quickly 
supervene  upon  a  period  of  ill-defined  malaise,  slight  shortness  of  breath, 
and  tendency  toward  fatigue.  Thus  the  development  of  the  condition 
is  occasionally  founrl  to  lip  decidedly  insidious,  without  exhibition  of 
clinical  manifestations,  until  the  effusion  has  attained  such  size  as  to 
permit  pronounced  |)liysicai  signs.  On  the  other  hand,  the  onset  is 
not  infrequently  arute  and  attended  by  well-defined  symptoms,  even 
before  the  recognition  of  pericardial  exudation.  Often  complaint  is 
made  of  pain,  which  may  range  from  a  sharp,  agonizing  stab  to  a  mere 
sense  of  oppression  referred  to  the  precordia.  The  pain  may  be  increased 
upon  pressure  at  the  lower  end  of  the  sternum.  A  beginning  shortness 
of  breath  in  acute  or  subacute  cases  rapidly  changes  to  a  marked  dysp- 
nea, which  necessitates  a  maintenance  of  the  upright  or  semireclining 
posture:     The  patient  is  tlistinctly  restless,  and  the  expression  anxious. 


398  roMPLiCATioxs 

There  is  almost  ahva.ys  pallor  or  slight  cj'anosis.  The  alae  of  the  nostrils, 
particularly  among  the  young,  are  seen  to  dilate  with  each  respiration. 
As  the  restlessness  increases  insomnia  or  delirium  may  supervene.  I 
have  seen  marked  hj-steria,  melancholia,  and  chorea  develop  in  severe 
cases,  and  have  recently  observed  pronounced  stammering  during  the 
height  of  the  effusion,  and  persisting  for  weeks  after  its  removal.  The 
pulse  is  always  rapid  and  frequently  irregular.  Many  observers  have 
described  the  pulsus  paradoxus,  characterized  by  an  extremely  weak 
and  feeble  pulse,  during  in.spiration. 

Upon  inspection  there  is  more  or  less  circumscribed  prominence  over 
the  precordial  region,  with  bulging  of  the  intercostal  spaces  and  in  some 
cases  edema  of  the  chest-wall.  Sometimes  the  respiratory  expansion 
of  the  left  chest  is  notably  diminished.  In  very  large  effusions  a  promi- 
nence in  the  epigastrium  may  be  produced  by  the  downward  displace- 
ment of  the  left  lobe  of  the  liver.  The  apex  impulse  may  be  feeble  or 
entirely  absent.  Upon  palpation  the  apical  impulse  is  frequently  oblit- 
erated completely,  particularly  in  the  event  of  a  large  effusion.  Though 
displaced  in  some  cases,  its  position  in  others  is  unaltered.  The  per- 
cussion signs  are  of  especial  importance,  chiefly  with  reference  to  a 
gradual  increase  in  the  area  of  cardiac  dulness.  The  lungs  offering  but 
little  resistance  to  the  encroachment  of  the  pericardium  are  correspond- 
ingly compressed.  There  is  considerable  difference  of  opinion  as  to  the 
configuration  of  the  dull  area,  many  writers  being  in  the  habit  of  describ- 
ing the  outline  as  irregular  or  pyriform  in  shape,  with  the  nari-ower  por- 
tion pointing  upward  towartl  the  manubrium  or  the  left  sternoclavicular 
notch.  For  practical  purposes,  in  outlining  this  area  in  pericardial 
effusion,  it  is  quite  justifiable  to  disregard  any  presupposed  idea  as  to  its 
pyramidal  shape.  The  essential  consideration  as  far  as  the  percussion 
outline  is  concerned,  is  the  mere  fact  of  a  symmetric  enlargement  of  t!ie 
area  of  dulness  in  all  directions.  In  extreme  cases  this  may  extend  far 
to  the  left  of  the  left  nipple,  to  the  right  well  l:)eyond  the  light  border  of 
the  sternum,  and  upward  as  far  as  the  clavicle.  Wien  the  outline  at 
the  base  and  lower  lateral  regions  is  suggestive  of  a  pyramidal  form,  the 
upper  portion  is  usually  somewhat  truncated,  the  upper  border  rarely 
conforming  to  an  apical  outline.  In  beginning  small  effusions  the 
changes  in  percus.sion  resonance  to  the  right  relate  to  an  increasing 
dulness  over  the  sternum  from  the  fourth  to  the  sixth  rib.  As  the 
effusion  increases  and  the  dull  area  encroaches  more  and  more  to  the 
right  of  the  sternum,  the  diminished  resonance  is  noted  in  the  neighbor- 
hood of  the  sixth  rib. 

Much  attention  has  been  directed  to  the  so-called  Rotch  sign,  which 
consists  of  the  obliteration  of  the  cardiohepatic  angle.  This  sign  is  not 
always  easy  of  exact  determination,  simple  as  it  may  seem,  and  to  the 
general  practitioner  is  not  of  especial  value.  Ewart  has  called  attention 
to  a  quadrangular  patch  of  percussion  dulness  in  the  left  infrascapular 
region.  Bamberger's  sign  consists  in  the  diminution  of  percussion 
resonance  in  the  lower  axilla,  and  about  the  angle  of  the  left  scapula, 
owing  to  pulmonary  compression.  While  it  is  possible  occasionally  to 
detect  an  increased  dulness  in  the  left  axilla,  it  must  be  conceded  that 
Bamberger's  sign  and  Ewart 's  sign  are  of  doubtful  value  in  the  average 
case.  Change  in  the  area  of  percussion  dulness  is  sometimes  produced 
by  a  change  in  the  position  of  the  patient. 

The  most  important  auscultatory  sign  is  the  progressive  enfeeble- 


TUBERCULOSIS    OF    THE    PERICARDIUM  399 

ment  of  the  heart-sounds,  which  in  some  cases  become  scarcely  aucUble. 
Preexisting  endocarchal  murmurs  are  usually  found  to  disappear  with 
an  increasing  effusion.  Worthin  calls  attention  to  the  frequent  accen- 
tuation of  the  pulmonary  second  sound.  Friction-rubs  heard  early  in 
the  case  disappear  with  the  development  of  the  effusion,  though  they 
are  sometimes  aucUble  at  the  bases. 

The  course  and  prognosis  depend  largely  upon  the  character  of  the 
effusion.  As  a  rule,  the  progress  is  slow  and  tedious  in  tulicrculous 
pericarditis,  though  in  serous  effusions  the  exudation  may  lie  al)sor1)ed 
with  coniiiuerable  rapidity.  Absorption  may  take  place  to  a  certain 
extent  even  with  purulent  effusions,  but  the  outlook  is  by  no  means 
good  in  such  cases. 

The  diagnosis  of  tuberculous  pericardial  effusion  is  often  attended 
by  the  greatest  difficulty.  The  observant  clinician  who  has  been  per- 
mitted to  watch  the  case  from  the  beginning  and  to  note  the  gradual 
but  progressive  development  of  physical  signs,  is  far  more  likely  to  anive 
at  an  accurate  cUagnosis,  than  the  consultant  who  is  called  upon  to  differ- 
entiate between  moderate  or  large-sized  pericardial  effusion  and  extreme 
cardiac  dilatation.  At  such  time  a  correct  determination  of  the  condition 
is  frequently  impossible  without  recourse  to  paracentesis.  It  is  not 
infrequent  that  the  most  skilled  examiners  are  found  to  be  in  error 
under  these  conditions. 

Attention  li.-is  hccn  icpcatcdly  called  to  the  wavy  character  of  the 
cardiac  impul^:;■  in  (lihilaiicin,  and  the  shock  or  slap  of  the  cardiac  sounds. 
In  cUlatation  tlie  urea  of  dulnoss  does  not  extend  upward  as  far  as  in 
effusion,  and  the  heart-sounds  arc  less  indisl  inct  or  muffled.  Important 
points  are  the  disappearanco,  in  crfusidu,  ul'  a,  ]iicviously  recognized 
endocarihal  murmur,  and  the  chunge  in  the  ;uf:i  oi  cardiac  dulness  upon 
change  of  posture.  Osier  calls  attention  to  the  fact  that  in  dilatation 
the  distention  is  rarely  sufficient  to  comjiress  the  kmg  and  produce  per- 
cussion changes  in  the  axillary  region.  I  have  seen  this  result,  however, 
in  a  notable  instance  of  cardiac  cUlatation  in  which  there  was  even  suffi- 
cient pulmonary  compression  to  occlude  entirely  a  primary  bronchus. 

Extreme  difficulty  of  diagnosis  may  be  presented  in  some  cases 
despite  an  intelligent  review  of  the  symptoms  and  physical  signs.  Even 
paracentesis  does  not  invariably  afford  a  positive  conclusion  concerning 
the  pathologic  condition,  as  will  be  illustrated  by  the  following  report 
of  a  case  recently  under  observation: 

The  patient  was  a  delicate  child,  ten  years  of  age,  with  a  distinct 
family  history  of  pulmonary  tuberculosis,  although  no  physical  evidences 
of  a  tuberculous  process  had  thus  far  been  recognized.  I  was  summoned 
at  the  end  of  a  period  of  malaise  and  lassitude  of  one  week's  duration. 
The  temperature  was  102°  F.,  pulse  108  and  of  good  quality.  The  child 
was  dressed  and  reclining  upon  a  couch  in  the  open  air,  but  manifested 
a  disinclination  to  sit  up.  The  expression  was  dull  and  the  face  mark- 
edly pale.  Complete  physical  examination  was  negative.  The  child 
was  put  to  bed  immediately  and  a  liquid  diet  instituted.  The  bowels 
were  thoroughly  moved,  and  the  salicylates  with  potassium  citrate 
administered.  Upon  the  third  day  a  faint  mitral  systolic  murmur  was 
heard  at  the  apex,  coincident  with  a  distinct  to-and-fro  pericardial 
friction-sound  over  the  right  ventricle.  There  was  slight  precordial 
discomfort,  but  complaint  was  made  of  severe  pain  in  the  left  shoulder. 
Upon  the  fourth  day  the  pain  continued  sharply  localized  in  the  shoulder. 


400  COMPLICATIONS 

but  was  also  intense  over  the  region  of  the  heart.  The  patient  was 
restless,  and  the  suffering  difficult  to  control  in  spite  of  hypodermics  of 
codein  and  finally  of  morphin.  Meantime  the  temperature  had  risen 
to  104°  F.  and  pulse  to  130.  The  bowels  were  obstinately  constipated. 
A  beginning  dyspnea  was  noted  in  connection  with  slight  cyanosis.  The 
pericardial  friction-sound  cUsappeared  at  the  end  of  twenty-four  hours, 
but  the  endocardial  murmur  persisted  for  several  days.  A  diagnosis  of 
pericarditis  had  been  rendered,  and  a  blister  two  inches  square  produced 
over  the  precordium.  This  was  attended  by  considerable  benefit  for 
about  a  day  and  a  half,  during  which  time  the  child  was  thoroughly 
purged  with  calomel.  Appeal  was  made  to  the  skin  and  kidneys, 
and  cartliac  stimulants  cautiously  administered.  A  progressive  increase 
in  the  area  of  cardiac  dulness  was  noted.  Impaired  resonance  was 
recognized  well  to  the  right  of  the  sternum  and  to  the  left  of  the  left 
nipple,  with  a  continual  upward  rise  of  the  area  of  dulness.  The  pain 
over  the  precordial  region  increased  in  severity  and  the  child  became 
hysteric  and  almost  unmanageable.  The  dyspnea  was  pronounced,  as 
was  also  the  cyanosis.  The  respirations  were  nearly  fifty  to  the  minute, 
the  alse  of  the  nose  dilating  markedly.  The  cardiac  impulse  became 
much  enfeebled,  and  finally  disappeared  altogether.  The  heart-sounds 
were  distant  and  muffled.  With  the  increase  of  effusion  the  endocardial 
murmur  became  more  indistinct  and  was  finally  incapable  of  recognition. 
Despite  active  cardiac  stimulation  the  condition  became  extremely 
desperate  by  the  end  of  one  week.  There  was  orthopnea,  insomnia, 
excruciating  pain  over  the  heart,  a  temperature  ranging  from  104°  to 
over  105°  F.  at  all  hours  of  the  day,  with  a  pulse  of  144  to  150,  and  of 
exceedingly  poor  quality.  The  cardiac  dulness  extended  to  the  second 
rib,  slightly  over  an  inch  to  the  right  of  the  sternum,  and  an  inch  and  a 
half  to  the  left  of  the  left  nipple.  The  chagnosis  appearing  unquestion- 
able, I  determined  to  perform  immediate  paracentesis  of  the  pericardial 
sac.  Before  resorting  to  this  proceilure  I  requested  counsel  and  received 
a  confirmation  of  the  diagnosis  and  indorsement  of  the  aspiration  by 
Drs.  Hall,  Powers,  and  Emery.  The  puncture  was  made  by  Dr.  Powers 
in  the  fifth  interspace,  an  inch  and  a  half  to  the  left  of  the  left  margin  of 
the  sternum.  The  needle  was  inserted  not  over  three-quarters  of  an 
inch.  The  aspirated  fluitl  presented  all  the  appearance  of  pure  blood,  of 
which  twelve  ounces  were  withdrawn.  Coagulation  of  the  blood  took 
place  in  the  receiving  bottle  liefore  the  aspiration  was  completed.  Des- 
pite our  consternation  at  the  sight  of  a  fluid  which  scarcely  could  be 
described  as  a  sanguineous  exudate,  but  rather  as  blood  from  a  ventricle, 
the  aspiration  was  continued  as  long  as  the  flow  persisted.  The  natural 
impulse  upon  the  first  appearance  of  the  blood  to  withdraw  the  needle 
was  restrained,  chiefly  because  there  was  no  visitile  movement  of  the 
needle,  as  might  be  expected  in  case  the  ventricle  \\:is  iMcncd.  While 
it  was  conceivable  that  in  the  event  of  a  greatly  iHI.himI  Ikmi-i  the  vas- 
cular contractions  might  impart  but  slight  nuncuieiit  U>  the  needle, 
complete  absence  of  impulse  suggested  that  the  point  remained 
within  the  pericardial  sac.  This  conclusion  was  strengthened  by  the 
knowledge  of  its  comparatively  superficial  insertion.  The  improvement 
in  the  child's  appearance  and  respiration  was  immediate  and  pro- 
nounced. He  also  experienced  decided  relief  from  pain.  Directly 
following  the  withdrawal  of  the  needle  I  outlined  with  care  the  area 
of  heart  dulness,  anil  the  result  was  corroborated  by  the  other  physi- 


TUBERCULOSIS    OF    THE    PERICARDIUM 


401 


cians  present.  The  size  of  the  heart  was  found  to  be  reduced  remark- 
ably, as  shown  by  Fig.  110,  which  is  taken  from  a  photograph  illustrating 
the  lines  of  cardiac  flatne.ss  immediately  prior  to  and  following  the  oper- 
ation. A  record  was  taken  of  the  boundaries  of  cardiac  dulness  and  the 
outlines  were  indicated  upon  the  chest  following  recovery.  The  tempera- 
ture was  104f  °  F.  at  the  time  of  operation,  and  at  the  end  of  six  hours 
had  dropped  to  101°  F.,  with  corresponding  improvement  in  the  pulse 
and  general  condition.  Shortly  after  the  aspiration  a  returning  endocar- 
dial murmur  was  recognized,  together  with  greater  chstinctness  of  the 
heart-sounds  and  a  gradual  reappearance  of  the  impulse.  The  aspirated 
blood  was  found  by  Dr.  W.  C.  Mitchell  to  be  absolutely  sterile  upon 
bacteriologic  examination. 

During  the  next  few  weeks  the  child  improved  progressively  in  all 
respects,  the  temperature  finally  recechng  to  normal,  and  the  pulse 
remaining  in  the  neighborhood  of  from  96  to  108.  Pain  entirely  chs- 
appeared,  as  did  dyspnea,  cyanosis,  and  all  other  subjective  symptoms. 


Fig.  110.— The  upper  and 
for  suspected  pericardial  effusi 
of  twelve  ounces  of  blood. 

There  persisted,  however,  a  loud  .systolic  murmur  at  the  apex,  with  a 
noticeable  wavy  cardiac  impulse.  The  dull  area  then  extended  slightly 
to  the  right  of  the  sternum  and  half  an  inch  to  the  left  of  the  left  nipple. 
It  would  appear  that  were  the  child  to  be  seen  for  the  first  time  uiitler 
these  later  concUtions,  the  diagnosis  of  chlatation  would  be  almost 
unavoidable.  I  was  forced  to  assume  that  regardless  of  what  the  pre- 
vious condition  might  have  been,  the  heart  was  now  moderately  dilated. 
Although  the  child  was  improving  steadily,  I  decided  at  the  end  of  one 
month  following  the  operation,  to  relieve  the  heart  as  much  as  possible 
by  sencUng  the  patient  to  a  lower  altitude,  and  at  the  same  time  to  give 
him  the  benefit  of  the  Nauheim  treatment.  He  was  accordingly  referred 
to  Dr.  Babcock,  of  Chicago,  under  whose  supervision  he  remained  for 
six  weeks.  The  child  has  continued  to  improve  steadily  since  his  return 
to  Colorado,  and  at  the  present  time,  one  year  after  his  initial  attack, 
shows  no  evidence  of  dilatation  and  but  a  scarcely  perceptible  endo- 
cardial murmur.     The  question  arises,  did  the  child  have  originally  a 

26 


402  COMPLICATIONS 

pericardial  effusion  consisting  of  pure  blood,  which  coagulated  imme- 
diately, or  was  the  blood  withdrawn  from  the  ventricle?  Irrespective  of 
the  diagnosis  there  can  be  no  doubt  that  life  was  saved  by  the  operation, 
and  that  even  ventricular  aspiration  is  rational  treatment  for  an 
extremely  dilated  heart. 

Opinions  may  differ  as  to  the  actual  condition  which  existed  in  this 
case.  It  is  certainly  unusual  to  remove  a  fluid  from  the  pericardial  sac 
presenting  all  the  gross  appearances  of  blood  with  its  nature  confirmed 
by  examination.  On  the  other  hand,  it  is  equally  difficult  to  reconcile 
certain  features  of  this  case  with  the  presence  of  a  dilated  heart.  The 
early  symptoms  and  physical  signs  were  distinctly  those  of  an  increr^idng 
pericardial  effusion.  The  shape  of  the  dull  area  corresponded  to  the 
expected  outline  of  effusion.  The  muffling  of  the  heart-sounds  and 
disappearance  of  the  murmur  before  the  aspiration,  with  subsequent 
return,  lend  color  to  the  accuracy  of  the  diagnosis.  This  is  further 
strengthened  by  the  absence  of  movement  imparted  to  the  needle,  the 
short  distance  of  its  insertion,  and  the  immediate  reduction  in  the  size 
of  cardiac  dulness.  On  the  other  hand,  it  is  almost  indisputaljle  that 
the  heart  was  distinctly  dilated  two  weeks  after  the  aspiration  and 
remained  so  for  a  month  or  six  weeks.  It  would  seem  that  if  the  orig- 
inal diagnosis  of  effusion  is  correct,  the  only  rational  explanation  of  the 
resulting  dilatation  is  found  in  the  formation  of  epicardial  and  peri- 
cardial adhesions,  of  such  extent  as  to  embarrass  the  cardiac  movement 
and  occasion  temporary  dilatation.  The  difficulties  attending  a  definite 
diagnosis,  regardless  of  possible  tuberculous  infection  ami  the  responsi- 
bilities involved  in  the  adoption  of  pericardial  paracentesis,  are  better 
appreciated  throusi'h  the  force  of  a  vivid  experience  than  by  the  perusal 
of  classics  pertaining  to  the  differential  diagnosis. 

Treatment. — Rest  constitutes  the  es.sential  feature  of  treatment 
of  pericarcUal  effusions,  whether  or  not  tuberculous.  Medicinal 
measures  are  of  doubtful  efficacy.  Many  cases  improve  without  other 
treatment  than  absolute  rest,  and  others  are  found  to  go  from  bad  to 
worse,  irrespective  of  the  nature  of  the  therapeutic  agencies  employed. 
Opiates  are  indicated  for  the  relief  of  pain  and  sometimes  to  promote 
sleep.  I  am  satisfied  that  their  application  in  such  cases  is  more 
rational  than  the  indiscriminate  administration  of  hypnotics,  which  are 
likely  to  depress  the  heart  to  a  certain  extent.  Although  lilisters  are 
considered  inadvisable  by  some  writers  unless  the  signs  of  effusion  have 
become  very  apparent,  it  is,  nevertheless,  excellent  practice  to  resort  to 
their  use  early  in  the  disease.  I  can  see  no  possible  ol)jection  to  their 
employment  after  the  diagnosis  has  been  determined,  and  but  little  to 
be  gained  by  delaying  until  the  effusion  has  become  of  large  size.  It 
appears  that  their  efficacy  is  largely  dependent  upon  the  time  of  their 
employment.  It  is  not  clear  that  recourse  to  a  blister  interferes  mate- 
rially with  a  close  study  of  the  physical  signs,  and  rarely  with  peri- 
cardial puncture.  Active  purgation  is  not  always  permissible,  but 
is  sometimes  indicated  in  fairly  robu.st  patients.  In  early  stages  the 
application  of  the  ice-bag  over  the  region  of  the  heart  is  of  some  value, 
and  often  affords  considerable  relief  to  the  precordial  discomfort. 
Salicylates  are  of  doubtful  utility,  and  when  pushed  indiscriminately, 
are  apt  to  depress  the  heart.  In  such  cases  potassium  iodic!  is  one  of  the 
be.st  cardiac  sedatives. 

There  is  a  wide  difference  of  opinion  as  to  the  site  of  election  in 


TUBERCULOSIS    OF   THE    PERICARDIUM  403 

making  the  pericardial  puncture.  The  left  costoxiphoid  angle  is  pre- 
ferred by  many,  who  thrust  the  needle  upward  and  backward  from  this 
point.  This  site  is  more  satisfactory  in  case  of  extremely  large  effusions 
than  under  other  conditions.  The  fourth  interspace  at  the  left  sternal 
margin  or  at  an  inch  and  a  cjuarter  from  the  margin,  as  well  as  the  fifth 
interspace  an  inch  and  a  half  from  the  edge  of  the  sternum,  are  respec- 
tively advised.  Some  clinicians  in  the  presence  of  large  effusions  ai'e 
in  the  habit  of  aspirating  to  the  left  of  the  left  nipple,  the  effort  t)eing 
made  to  insert  the  needle  just  in.side  the  outer  left  border  of  dulness. 
Personally  I  am  not  aWe  to  indorse  aspiration  other  than  through  the 
small  area  over  the  ventricle  where  the  lung  does  not  come  in  immediate 
apposition  to  the  die; 't- wall. 

In  theeventof  apurulent  cffii:  ion  surgical  measures  should  be  imme- 
diately instituted.  They  c<iMsi:i  <>f  lice  incision,  sometimes  resection  of 
rib,  and  the  maintenance  of  rdiitiiiiiniis  drainage,  affording  a  thorough 
evacuation  of  thick  pus  and  coaguhiljlc  flocculi. 

ADHERENT  PERICARDIUM 

There  are  two  forms  of  adherent  pericardium.  In  one  group  there  is 
present  a  simple  ailhesion  of  the  pericardial  and  epicardial  layers.  In 
these  cases  the  surrounding  structures  are  frecjuently  uninvolved, 
although  there  may  be  a  considerable  union  of  the  two  laycr.'^.  In 
another  group  adhesions  are  formed  between  the  outer  laj^er  of  the  peri- 
cardial sac  and  the  chest-wall,  diaphragm,  and  pleura,  by  virtue  of  their 
immediate  contiguity.  The  parts  may  be  fused  closely  together  and  be 
associated  with  more  or  less  mediastinal  connective-tissue  formation. 

The  symptoms  incident  to  the  presence  of  pericardial  adhesions, 
irrespective  of  other  cardiac  lesions,  vary  according  lo  llicir  cxlcnt  and 
situation.  In  the  event  of  simple  adhesions  of  tlie  two  lasers  of  ihc  sac 
there  may  be  no  symptoms  whatever,  although  hypertrophy  ocia-ionally 
may  result.  Dr.  Babcock  has  called  attention  to  the  occasional  union  of 
the  two  surfaces  of  the  pericardium  tluring  the  time  the  luari  i>  .iiiitcly 
dilated,  either  as  a  result  of  niyo<':u(litis  oi-  of  \alviila,i-  di  case,  liider 
.such  circumstances  its  romplete  diniinuiion  in  si/.e  i<  alnio-i  ini|io— iMe, 
and  a  disturbance  in  its  function  is  (piife  inevitable.  When  the  adhe- 
sions are  external  to  the  sac  and  involve  neighboring  structures,  the 
condition  is  of  much  more  serious  import,  owing  to  the  unavoidable 
restriction  in  the  movements  of  the  heart  and  consequent  emljarrassment 
of  its  function.  Hypertrophy,  dilatation,  and  circulatory  stasis  are 
frequent.  There  are  often  palpitation,  dyspnea,  broiicliial  i  nit  at  ion 
Avith  weak  pulse,  and  digestive  disturbance.  The  li\er  is  someiinies 
enormously  enlarged  from  passive  congestion.  In  some  i  asi's,  however, 
the  liver  bcomes  much  reduced  in  size  through  conneiii\(Missue  pro- 
liferation, and  the  condition  may  suggest  chronic  interstitial  hepatitis. 

The  physical  signs  upon  inspection  relate  to  the  prominence  of  the 
precordium,  and  a  more  or  less  exten.sive  dift'usion  of  the  carchac  impulse, 
with  occasional  displacement  of  the  apex.  The  impulse  is  often  undu- 
latory  over  a  wide  area,  transgressing  frequently  the  limits  of  the  normal 
precordial  region.  In  some  cases  there  is  ininiohility  of  the  apex 
impulse,  either  with  a  change  in  the  position  of  the  body  or  during  full 
inspiration.  During  .systole  a  tugging  retraction  of  the  chest- wall 
is  commonly  noted  in  the  lower  left  epigastric  region.     This  may  be 


404  COMPLICATIONS 

followed  by  a  diastolic  rebound  of  the  interspaces  immediately  over  the 
point  of  apex  retraction. 

Broadbent's  sign  consists  of  a  visible  systolic  retraction  of  the  chest- 
wall,  not  only  in  the  region  of  the  seventh  or  eighth  ribs  in  the  left  para- 
sternal line,  but  also  between  the  ele\enth  antl  twelfth  ribs  on  the  left 
side  behind,  at  the  point  of  attachment  of  the  lUaphragm. 

Friedreich's  sign  consists  of  the  diastolic  coUapse  of  the  cervical  veins 
ascribed  to  the  sudden  emptying  of  these  vessels  as  a  result  of  the  expan- 
sion of  the  chest-waU. 

A  paradoxic  pulse,  though  less  common  than  in  acute  pericarditis, 
is  sometimes  recognized  upon  palpation,  owing  to  the  traction  of  the 
cicatricial  mediastinal  tissue  upon  the  aorta  during  inspiration. 

The  percussion  signs  relate  to  an  increase  in  the  area  of  cardiac  dul- 
ness,  owing  to  hypertrophy  and  dilatation,  which  may  be  extreme. 
Irrespective  of  the  presence  of  endocarihal  murmurs,  which  are  occa- 
sionally dependent  upon  the  dilatation,  the  important  auscultatory  signs 
are  the  pleuropericarchal  friction-sounds.  These  sounds  may  be  heard 
both  with  inspiration  and  expiration,  and,  as  a  rule,  are  distinctly 
creaking  in  character.  It  is  not  infrequent  to  find  the  sound  consider- 
ably more  intensified  during  inspiration  than  expiration,  and  sometimes 
vice  versa.  It  often  disappears,  howe\'er,  upon  holding  the  breath.  It 
is  heard  to  best  advantage  over  the  left  border  of  the  heart. 

The  exact  determination  of  carcUac  hypertrophy  or  dilatation  among 
pulmonarj-  invalids  is  often  a  matter  of  extreme  difficulty,  even  by  most 
skilled  examiners.  From  a  comparison  of  the  results  of  my  own  chnical 
fincUngs  with  the  skiagraph  I  have  become  convinced,  first,  that  the 
heart  is  displaced  very  much  ojtener  than  woidd  he  imagined  from  the 
literature  upon  the  subject,  and,  secondly,  that  the  onlinary  methods  of 
percussion  and  auscultation  are  sometimes  quite  insufficient  to  afford 
an  accurate  determination  of  its  position  and  size  among  this  class  of 
patients.  This  has  been  cUscussed  more  fully  in  connection  with 
Diagnosis. 


CHAPTER    LVIII 

TUBERCULOSIS  OF  THE  PERITONEUM 

Tuberculosis  of  the  peritoneum  may  exist  as  one  of  the  local  manifes- 
tations of  acute  miliary  tuberculosis,  or  as  a  cUstinct  peritoneal  process 
of  more  or  le.ss  chronic  character.  When  the  condition  is  inciilent  to  a 
general  miliary  infection,  the  tubercles  are  diffu.sed  over  the  parietal  and 
visceral  layers  of  peritoneum,  without,  as  a  rule,  any  active  inflammatory 
change.  When  tuberculous  peritonitis  exists  as  a  local  condition  purely, 
the  inflammatory  condition  ma.v  be  accompanied  by  various  pathologic 
processes.  In  some  cases  there  is  an  extensive  proliferation  of  connec- 
tive tissue  with  numerous  adhesions  between  intestinal  coils  and  adjacent 
viscera,  with  occasionally  an  imj)lication  of  the  abdominal  walls.  In 
others  with  less  tendency  to  adhesions  there  is  found  a  pronounced  thick- 
ening of  the  peritoneum,  omentum,  and  mesentery  incident  to  their  infil- 
tration with  degenerative  tubercle  deposit.    This  form  is  sometimes 


TUBERCULOSIS    OF    THE    PERITONEUM  405 

characterized  by  the  presence  of  large  ulcerative  tuberculous  masses. 
Palpable  tumors  simulating  tuberculous  growths  are  produced  by  a 
localized  matting  and  drawing  of  the  intestines,  which  is  intensified  in 
some  instances  by  the  traction  exerted  by  a  shrunken  mesentery.  In 
still  another  group  of  cases  there  is  a  profuse  exudative  process.'  This 
may  be  unassociated  with  marked  pathologic  changes  within  the  peri- 
toneal cavity,  or  it  may  attend  the  proliferative  type,  with  multiple 
adhesions,  or  even  the  caseous  and  ulcerating  forms.  The  exudation 
may  be  serous,  seropurulent,  or  bloody  in  character,  and  may  be  general 
or  sacculated.  A  simple  general  ascites  of  insidious  or  very  acute  onset 
mthout  subjective  symptoms  may  accompany  a  developing  tuberculous 
deposit  unattended  by  other  pathologic  change.  In  some  cases  the  exu- 
dative processes  are  found  in  a.ssociation  with  extensive  connective- 
tissue  change.  It  is  manifestly  inijiroper  to  divide  all  cases  of  tuljer- 
culous  peritonitis,  aside  from  the  niiliai y  form,  into  two  distinct  classes 
— the  proliferative  and  the  exudati\('  kioujis     as  has  been  attempted. 

The  etiologic  relations  of  tiilxiculuus  jieiitonitis  have  been  the 
subject  of  much  clinical  study  and  investigation.  The  condition  is 
almost  always  secondary  to  some  other  tuberculous  focus,  the  primary 
source  of  infection  being  traced  to  the  lungs  in  the  large  majority  of 
cases.  At  least  foui'-fifths  of  ;ill  instances  of  tuberculous  peritonitis 
occur  in  association  \\ith  easily  i-pr( ionized  pulmonary  involvement. 
Cummins  has  reported  a  scries  dl'  cases  ill  wlmli  ,S4  per  cent,  succeeded 
pulmonary  tuberculosis  and  .'>!'. G  i)er  cent,  intestinal  involvement.  The 
same  observer  has  quoted  Priln-am's  report  of  the  result  of  165  autop- 
sies upon  cases  of  tulierculous  peritonitis,  of  which  87  were  attributed  to 
intestinal  tuberculosis.  65  to  glandular  disease,  8  to  tubal  and  uterine, 
and  5  to  osseous  tulierciiln-i-^.  Douglass  has  quoted  Borschke,  who 
failed  to  find  a  primary  focus  in  but  2  cases  out  of  226  of  peritoneal 
tuberculosis.  From  a  total  of  bil)3  autop.sies  upon  tuberculous  subjects, 
tuberculous  peritonitis  was  found  to  exist  in  226  cases,  or  16  per  cent. 
Peritoneal  invohcment  in  t\d)er(iilous  invalids  has  been  reported  by 
other  observers  to  vary  from  10  per  cent,  to  20  per  cent. 

Tuberculous  peritonitis  may  exist  at  any  time  of  life,  although 
observed  more  frequently  in  young  adults.  When  occurring  in  children, 
it  is  often  in  association  with  a  general  miliary  involvement.  Frederick 
C.  Shattuck  has  recently  reported  some  slatisiical  observations  upon  a 
series  of  98  cases  of  tuberculous  peritonitis  treated  at  the  Massachusetts 
General  Ho.spital  during  a  period  of  eleMii  years  from  1889  to  1900. 
The  youngest  was  thirteen  months  old,  while  the  oldest  was  sixty-two 
years.  Six  occurred  in  children  fron  one  to  five  years  of  age,  7  from 
five  to  ten  years,  8  from  ten  to  fifteen  years,  56  cases,  or  57.1  per  cent. 
of  the  whole  number,  between  the  ages  of  fifteen  and  lhirt>- years.  There 
were  13  cases  between  thirty  and  forty  and  but  s  cases  over  forty  years 
of  age.  In  view  of  the  fact  that  a  relatively  snudl  lumiber  of  children 
enter  the  Massachusetts  General  Hospital,  the  proportion  of  cases  among 
children  in  the  series  reported  by  him  is  perhaps  smaller  than  usual. 

Tuberculous  peritonitis  is  usually  conceded  to  exist  with  greater 
frequency  among  females,  although  some  observers  maintain  that  it  is 
more  common  in  the  male  sex.  It  would  be  reasonable  to  suppose  that 
the  statistics  should  favor  the  preponderance  of  the  condition  among 
females,  on  account  of  their  special  predisposition  to  infection  through 
the  genital  tract.     This  conclusion  seems  to  be  borne  out  by  the  obser- 


406  COMPLICATIOXS 

vations  of  surgeons,  which,  of  course,  are  based  upon  purely  operative 

cases. 

There  are  several  ways  in  which  the  peritoneum  is  known  to  become 
infected.  A  common  method  of  invasion  is  from  a  tuberculous  involve- 
ment of  the  wall  of  the  stomach,  or  of  the  small  intestine,  appendix,  or 
colon.  The  extension  of  the  tuberculous  process  into  the  peritoneum 
from  slowly  ulcerating  deposits  upon  the  intestinal  wall  in  some  cases 
gives  rise  to  purely  local  changes.  In  the  event  of  sudden  perforation 
of  the  tuberculous  ulcer  a  septic  general  peritonitis  rapidly  develops 
through  the  entrance  into  the  free  cavity  of  the  agents  of  decomposition. 
The  infected  area  is  sometimes  sharply  circumscribed  by  the  existence 
of  firm  adhesions  between  cUfferent  coils  of  intestine.  In  some  instances 
tliese  atlhesions  involve  the  parietal  peritoneum. 

Another  route  of  infection  is  that  resulting  from  the  caseation  and 
subsequent  perforation  of  mesenteric  or  retroperitoneal  lymph-glands. 
In  such  instances  the  tuberculous  process  may  become  cUffused  through- 
out the  free  peritoneal  cavity,  or  it  may  be  localized  through  the  forma- 
tion of  adhesions.  An  acute  septic  peritonitis  is  far  less  likely  to  result 
from  this  form  of  infection  than  from  tuberculous  intestinal  ulcers. 

The  mesenteric  glands  have  been  shown  to  become  infected  by 
the  migration  of  tubercle  bacilli  through  a  healthy  intestinal  wall,  an 
intact  mucous  membrane  constituting  no  proof  that  it  may  not  be  an 
atrium  of  infection.  As  stated  previously  with  reference  to  the  tonsil, 
the  tissue  at  the  point  of  invasion  may  be  less  favorable  for  the  growth 
and  development  of  tubercle  than  more  distal  parts. 

It  has  not  been  demonstrated  as  yet  that  the  peritoneum  may  become 
primarily  infected  by  the  passage  of  bacilli  through  a  normal  mucous 
membrane  without  first  producing  an  involvement  of  the  mesenteric  and 
retroperitoneal  glands.  The  fact  that  tuberculous  peritonitis  in  excep- 
tional instances  has  been  found  to  exist  in  the  absence  of  a  cUscoverable 
primary  focus  does  not  controvert  a  belief  in  the  secondary  nature  of 
the  infection.  * 

Another  pathway  of  peritoneal  infection  is  by  way  of  the  lymphatics 
from  the  pleura  through  the  diaphragm,  from  the  abdominal  or  pelvic 
organs  or  from  some  distant  focus. 

The  especial  frequency  of  peritoneal  tuberculosis  in  adult  females 
is  explained  in  part  by  the  facilities  for  cUrect  extension  from  the  female 
genital  organs.  The  Fallopian  tube  is  frequently  a  primary  focus  of  infec- 
tion, from  which  point  the  bacilli  may  gain  entrance  to  the  peritoneum, 
either  by  cUrect  extension  through  a  free  tubal  opening  or  by  means  of 
the  lymph-channels.  It  is  the  consensus  of  opinion  of  many  observers 
that  the  Fallopian  tubes  are  involved  in  a  large  proportion"  of  cases  of 
tuberculous  peritonitis,  which  i-  v:iii(iusly  estimated  at  from  2.5  to  .50  per 
cent.  There  seems  to  lie  -I'lnc  iliitcrouce  of  belief  as  to  whether  the 
involvement  of  the  tube  is  in  m'licial  the  cause  or  the  result  of  the  peri- 
toneal infection.  It  is  scarcely  necessary  at  this  time  to  review  the 
controversial  literature  bearing  upon  the  precise  direction  of  the  bacillary 
invasion,  whether  ascenchng  from  the  genitals  or  descending  from  the 
peritoneum.  It  is  .sufficient  to  state  that  the  authentic  oliscrvations  of 
many  authorities  appear  somewhat  conflicting  and  cont  rac  lictorv.  What- 
ever one's  theories  may  be  in  this  matter,  it  is  possible  to  secure  both 
corroborative  and  negative  testimony  as  to  their  correctness.  Mayo  has 
called  attention  to  the  fact  that  the  tuberculous  process  in  the  peritoneum 


TUBERCULOSIS    OF    THE    PERITONEUM  407 

is  especially  pronounced  in  the  immediate  neighborhood  of  the  primary 
focus  of  infection.  Certain  it  is  that,  irrespective  of  the  source  of  infec- 
tion, removal  of  the  tubes  is  followed  in  a  large  number  of  cases  by 
gratifying  improvement.  It  is  also  true  that  in  many  cases,  despite 
pronounced  tuberculous  involvement  of  the  tubes,  the  uterus  is  found 
to  present  an  entirely  normal  appearance.  Tuberculous  peritonitis  has 
been  reported  to  occur  along  the  route  of  the  male  generative  tract, 
although  this  route  of  invasion  is  decidedly  less  direct  than  in  females. 
Horowitz  describes  the  pathway  from  the  epididymis  through  the  lym- 
phatics of  the  spermatic  plexus  and  the  ampulla  end  of  the  vas  deferens. 
Osier  cites  seven  instances  in  which  the  sac  alone  is  involved. 

Cruveilhier  and  Haegler  have  reported  cases  of  primary  hernial  tuber- 
culosis. Cotte  reports  5  cases  of  apparently  primary  tuberculous  pro- 
cesses in  hernia,  together  with  a  summary  of  136  recorded  cases.  It  is, 
of  course,  easy  to  understand  how  hernia  may  take  place  in  subjects 
afflicted  with  tuberculosis  of  the  peritoneum  with  associated  infection  of 
the  sac,  or  of  the  intestinal  coils  therein  contained,  hut  it  is  liard  to  com- 
prehend why  there  should  exist  any  inherent  susce])til)ility  to  hernial 
tuberculosis  independent  of  the  peritoneum  itself. 

Symptoms. — The  symptoms  of  tuberculous  peritonitis  are  somewhat 
variable,  according  to  the  type  of  peritoneal  involvement.  The  con- 
dition is  of  acute  onset  in  but  a  small  proportion  of  cases.  Shattuck 
reports  29  of  acute  onset  out  of  a  total  of  98.  Personally,  I  have  seen 
but  3  cases  of  acute  tuberculous  peritonitis,  exclusive  of  the  localized 
infections  coexistent  with  a  tuberculous  appendix.  In  the  latter  event 
the  onset  is  often  sudden,  presenting  rapidly  fulminating  symptoms. 
Several  of  my  pulmonary  invalids  have  exhibit (.'li  tuberculous  appendi- 
citis with  a  localized  peritoneal  invasion  of  subacute  type. 

In  the  majority  of  instances  tuberculous  peritonitis  is  of  slow,  gradual 
development.  While  the  course  of  the  disease  usually  conforms  to  the 
chronic  type,  there  may  occur  for  a  time  acute  exacerbations,  periods 
of  improvement  being  followed  by  recurriiji;  iclapses.  1  ic(:ill  sc\-ei-al 
cases  of  remarkably  slow  and  insicUous  ousel,  wliich,  aftef  tlie  lapse  of 
several  years,  exhibited  periods  of  severe  pain  with  other  acute  mani- 
festations which  gradually  subsided,  but  were  followed  by  intervals  of 
abdominal  chscomfort. 

Acute  cases  of  tuberculous  peritonitis  are  always  characterized  by 
rather  extreme  pain,  and  usually  by  tenderness  and  tympanites.  The 
pain,  however,  is  not  always  of  an  acute  character,  and  in  some  cases 
is  but  little  more  than  a  sense  of  abdominal  discomfort,  with  occasional 
intercurring  colicky  attacks.  It  is  increased  by  intra-abdominal  pies- 
sure,  the  tension  upon  the  abdominal  wall  often  being  sufficient  to  pi'o- 
duce  a  voluntary  flexion  of  the  thighs  upon  the  abdomen.  This  position 
is  suggestive  of  acute  general  peritonitis. 

Nausea  and  vomiting  are  quite  common  in  the  acute  type,  but  are 
rarely  present  in  the  chronic  form,  in  which  the  symptoms  are  rather 
vague  and  ill  defined.  The  severity  of  such  acute  symptoms  as  pain, 
distention,  tenderness,  nausea,  and  vomiting,  w-ith  weak  and  rapicl 
pulse,  is  largely  dependent  upon  the  extent  of  peritoneal  involvement. 
In  the  event  of  a  general  peritonitis  these  symptoms  rapidly  develop, 
and  are  attended  by  great  prostration  and  followed  shortly  by  a  speedy 
fatal  termination. 

In  circumscribed  tuberculous  peritonitis  the  symptoms  are  consider- 


408  COMPLICATIONS 

ably  less  severe.  Both  the  pain  and  tenderness  are  localized,  while  the 
vomiting  is  less  frequent  and  sometimes  of  but  short  duration.  The 
fever  may  be  quite  as  high  as  in  general  peritonitis,  but  the  cases  run  a 
much  longer  course,  sometimes  ending  in  apparent  recovery  after  a 
prolonged  convalescence. 

The  physical  examination,  exclusive  of  the  determination  of  tender- 
ness or  rigidity,  relates  to  the  detection  of  fluid  and  the  recognition  of 
definitely  circumscribed  masses.  In  cases  characterized  by  excessive 
exudation,  dulness  is  obtained  upon  percussion.  This  is  early  recog- 
nized in  the  flanks,  and  is  found  to  vary  in  location  with  a  corresponding 
change  in  the  position  of  the  patient.  As  the  fluid  increases  the  dulness 
in  some  cases  becomes  general  and  fluctuation  is  detected.  Rising  of 
the  cUaphragm,  acceleration  of  the  respiration,  and  alteration  in  the 
position  of  the  cardiac  apex  is  possible  in  severe  cases. 

Circumscribed  collections  of  fluid  are  recognized  by  palpation,  chiefly 
in  the  form  of  rounded,  fluctuating  tumors.  Sometimes,  however,  on 
account  of  the  extreme  ten.sion  of  the  contained  fluid  they  appear  as 
resisting  masses.  Hard,  unyielding  tumors  ma.y  be  present,  which 
strongly  simulate  solid  neoplasms  of  various  organs.  These  masses, 
either  solid  or  apparently  so,  maj^  occur  in  almost  any  portion  of  the 
abdominal  cavity  and  resemble  almost  any  conceivable  new-growth. 
They  may  occur  in  the  right  or  left  epigastric  region,  in  either  hypo- 
chondrium,  above  the  pubis,  in  the  right  or  left  iliac  fossa,  ami  in  the 
neighborhood  of  the  umbilicus.  The  location  of  the  induration  and  the 
simulation  of  solid  growth  are  often  sufficient  to  confound  the  most 
experienced  examiner.  It  is  possible  at  times  to  appreciate  a  distinct 
peritoneal  friction  or  crepitation,  which  affords  quite  definite  infor- 
mation as  to  the  character  of  the  involvement. 

Diagnosis. — The  (Uagno.sis  may  be  comparatively  simple  in  many 
cases,  but  in  others  it  is  often  exceechngly  cUfficult.  Acute  perforative 
cases  exhibiting  a  sudden  and  violent  onset  are  seldom  regarded  in  the 
beginning  as  instances  of  tuberculous  peritonitis.  Such  cases  are  likely 
to  be  confused  with  appendicitis,  strangulated  hernia,  and  the  common 
form  of  acute  peritonitis,  a  positive  tUagnosis  often  not  being  established 
until  the  abdominal  (•a\ity  has  lieen  opened.  In  internal  hernia  and 
acute  intestinal  obstruction  from  other  cause  the  pain,  as  a  rule,  is 
localized  and  paroxysmal.  In  such  cases  the  abdominal  distention  is 
due  to  gas  rather  than  to  fluid,  and  constipation  is  common.  The  earl_y 
vomiting  soon  becomes  fecal  in  character.  In  appendicitis  the  onset  is 
usually  acute,  but  the  rigidity,  pain,  and  tenderness  are  localized  in  a 
definite  area  in  the  immediate  region  of  the  appendix.  While  tumor-like 
masses  are  often  present  in  tuberculous  peritonitis,  they  are  exceedingly 
rare  in  the  acute  fulminating  type,  pxliiMtiuir  a  violent  onset.  In  some 
cases  of  appendicitis  despite  the  lii^t.ny  <,<  cliill.  ia|'id  puNc  .■uid  vomit- 
ing, there  may  be  elicited  by  phy.sical  cxaiiiiii.-iiidii  imi  t  lie  -li^h test  exter- 
nal evidence  of  its  presence.  Per  coulra  lliei-c  nuiy  l>e  luuud  a  sharply 
localized  area  of  resistance  and  tenderness  over  the  region  of  the  appen- 
dix, without  associated  subjective  symptoms.  This  will  he  considered 
more  fully  in  connection  ■\\ith  tuberculosis  of  the  appendix  and  simple 
appendicitis  among  pulmonary  invalids. 

Difficulties  of  diagnosis  also  attend  the  chronic  forms  of  general 
tuberculous  peritonitis.  In  these  cases  the  condition  at  times  may  be 
essentially  latent,  and  give  rise  to  no  symptoms  whatever.     The  cUagno- 


TUBERCULOSIS    OF    THE    PERITONEUM  409 

sis  is  often  made  at  the  time  of  an  operation  for  some  other  condition 
among  individuals  in  excellent  nutrition.  There  may  be  absence  of 
fever  or  of  previous  suspicion  of  tuberculous  involvement.  Peritoneal 
infection  is  undoubtedly  present  more  frequently  among  pulmonary 
invalids  than  is  commoiily  supposed.  Many  consumptives  with  quies- 
cent pulmonary  infection,  display  abdominal  tenderness,  moderate 
distention,  and  continuous  slight  elevations  of  temperature  without 
explainalile  cause  other  than  the  hypothesis  of  a  mild  peritoneal  infec- 
tion. This  group  of  symptoms  in  the  presence  of  a  known  tuber- 
culous lesion  in  the  lung  capable  of  producing  temperature  elevation, 
is  often  attributed  to  disturbances  of  digestion.  Many  of  these  cases 
exhibit  recurring  attacks  of  slight  colicky  pain,  which  is  more  or  less 
vague  and  indefinite  in  localization.  The  per.sistence  of  such  mani- 
festations among  consumptives  is  sufficient  to  suggest  the  possible 
existence  of  a  chronic  peritoneal  tuberculosis.  Especial  confusion  is 
likely  to  be  experienced  in  the  differentiation  of  the  circumscribed  exuda- 
tions and  tumor-like  masses  from  the  solid  neoplasms  or  fluctuating 
tumors  peculiar  to  certain  organs. 

It  is  hardly  appropriate  to  infringe  upon  the  domain  of  surgery  and 
enter  upon  a  necessarily  detailed  consideration  of  technical  diagnostic 
features  pertaining  to  the  simulation  of  cysts  of  the  pancreas,  pyonephro- 
sis, empyema  of  the  gall-bladder,  hydatid  cysts,  ovarian  tumors,  pus- 
tubes,  pelvic  disease,  and  new-growths  in  the  stomach  or  intestine.  A 
precise  diagnosis  is  often  out  of  the  question  without  an  exploratory 
operation.  A  tuberculous  omental  tumor,  however,  presents  somewhat 
fewer  difficulties  than  the  more  definitely  circumscribed  masses,  because 
of  its  characteristic  elongated  shape.  When  the  omentum  is  the  seat  of 
tuberculous  infection,  it  is  sometimes  stretched  across  the  abdomen  in  a 
firm  mass  which  is  attached  to  the  transverse  colon  a  little  above  the 
region  of  the  umbilicus.  This  hard,  band-like  mass  may  be  similarly 
situated  in  cases  of  carcinoma,  though  less  often  than  in  tuberculous 


In  doubtful  cases  the  existence  of  tuberculosis  elsewhere  should 
afford  a  reasonable  assumption  as  to  the  nature  of  a  local  peritoneal 
involvement.  In  the  event  of  an  undiscoverable  tuberculous  focus 
in  other  parts  of  the  body  a  distinct  family  history  of  this  disease 
is  of  undoubted  significance,  as  is  also  the  admission  of  an  idiopathic 
pleurisy,  glandular  enlargements,  or  caries  of  bone.  It  has  been  shown 
quite  conclusively  that  the  tuberculin  reaction  in  obscure  cases  is  of 
unmistakable  value.  If  this  is  absent,  a  reasonable  doubt  may  be  enter- 
tained as  to  the  tuberculous  nature  of  the  affection,  while  a  positive 
result  is  strong  prima  facie  evidence  of  such  condition.  In  douljtful 
cases  recourse  to  the  ophthalmotuberculin  test  is  worthy  of  trial. 
As  indicated  previously  the  age  is  often  an  important  determining 
factor. 

I  have  in  mind  the  case  of  an  intimate  friend,  thirty-five  years  old, 
of  tuberculous  family  history.  He  was  well  nourished  and  unusually 
robust,  but  in  the  midst  of  apparent  health  experienced  a  severe  rigor 
with  sliarp  pain  in  the  left  lower  abdomen,  followed  by  vomiting  and 
abrupt  elevation  of  temperature.  Upon  examination  tenderness  and 
resistance  were  at  once  detected.  Had  the  physical  signs  existed  upon 
the  right  side,  instead  of  the  left,  the  conclusion  would  have  been 
unavoidable  that  the  condition  was  acute  appendicitis  demanding  imme- 


410  COMPLICATIONS 

diate  operative  interference,  and  in  this  connection  the  possibUitj-  of 
transposition  of  the  viscera  was  entertained.  Drs.  Powers  and  Bagot 
concurred  in  the  non-advisability  of  immediate  exploratory  laparotomy 
and  counseled  for  the  time  being  a  policy  of  delay.  After  weeks  of  recur- 
ring pain  and  nausea,  with  progressive  emaciation  and  physical  debility, 
following  the  subsidence  of  the  initial  violent  symptoms,  an  exploratory 
operation  disclosed  extensive  tuberculous  involvement  of  the  perito- 
neum with  multiple  atlhesions  of  intestinal  coils.  There  had  previously 
been  recognized  upon  examination  a  firm,  hard,  linear  mass  extending 
from  the  left  iliac  fossa  upward  into  the  flank  for  a  distance  of  five  to 
six  inches.  This  mass  was  found  to  be  due  to  a  localized  proliferative 
and  adhesive  peritonitis,  the  fibrous  tissue  growth  being  especially 
marked.  The  patient  survived  but  a  few  days  following  the  operation. 
The  acute  onset  of  abdominal  symptoms  took  place  less  than  two  weeks 
following  an  accident  while  riding  horseback  through  an  almost  impene- 
trable region  in  the  mountains,  the  horse  in  falling  ha\'ing  pressed  upon 
the  abdomen  with  great  force.  The  thought  is,  therefore,  suggested 
that  the  tuberculous  involvement  may  have  lieen  of  traumatic  origin. 

Prognosis. — The  prognosis  of  tuberculous  peritonitis  varies  in 
accordance  with  the  age,  the  severity  of  the  infection,  the  extent  and 
character  of  the  involvement,  and  the  general  condition  of  the  patient. 
In  young  children,  particularly  if  of  tuberculous  parentage,  the  outlook 
is  less  favorable  than  in  adults.  Acute  cases  of  suppurative  peritonitis 
following  perforation  are  almost  invariably  fatal.  Localized  tuberculous 
involvement,  even  if  acute,  is  not  necessarily  hopeless,  though  uniformly 
of  grave  significance.  Exudati\'e  cases  possess  a  much  more  favorable 
prognostic  import  than  the  adhesive  and  proliferative  forms.  Many 
cases  are  amenable  to  cure,  as  the  result  of  either  medical  or  surgical 
management.  Of  Shattuck's  25  cases  subjected  to  me(hcal  treatment 
alone,  the  mortality  was  68  per  cent.,  which  is  accounted  for  in  part  by 
the  fact  that  in  all  but  6  of  these  cases  there  were  present  other  important 
complications.  Among  his  57  cases  submitting  to  surgical  operation  the 
mortality  was  47. .3  per  cent.  An  analysis  of  Shattuck's  report  disclo.sed 
the  fact  that  the  most  favorable  results  were  obtained  in  the  non-exu- 
dative cases,  while  the  mortality  was  high  in  ascitic  cases  irrespective 
of  the  nature  of  the  fluid.  These  results  are  at  variance  with  the  usual 
conception  of  the  prognostic  im]mrt  attaching  to  the  exudative  type  as 
compared  with  ca--c~  cxhil.ii  inn  well-dcliuccl  masses.  As  a  rule,  the 
subacute  or  chronic  cMiilatiNc  iornis  fiunish  the  host  results,  particularly 
if  subjected  to  opi'r;iii\r  inicrfei'ence.  JMotlern  opinion  regarding  the 
manner  in  which  iiii|ii(i\ciiiciit  is  secured  in  such  cases  as  a  result  of 
opening  the  abdomen,  im  lims  toward  an  increased  phagocyting  power 
of  the  white  blood-cells  by  virtue  of  the  direct  entrance  of  air  into  the 
abdominal  cavity,  or,  in  accordance  with  tiie  theory  of  Wriglit.  tlie 
presence  of  a  new  exudate  rich  in  opsonins.  Cameron  calls  attention  to 
the  hichly  favorable  influonre  resulting  from  the  stimulation  given  to  the 
lympliaiic  and  vasciiluT  circulations  on  account  of  the  trauma  and  the 
reduccil  nitia-a.b.loniiual  iii-cssure. 

It  is  apparent  that  ojieration  offers  but  little  to  patients  exhibiting 
the  fibrous  obliterative  type  or  ulcerous  form.  The  existence  of 
advanced  tuberculous  infection  in  other  parts  of  the  boily  adds  to  the 
gravity  of  the  prognosis.  The  same  is  true  of  suppurative  proce.sses, 
persisting  fever,  diarrhea,  and  progressive  loss  of  weight.     Generally 


TUBERCULOSIS    OF    THE    PERITONEUM  411 

speaking,  about  50  per  cent,  of  all  cases  may  reasonably  be  expected  to 
improve,  if  not  absolutely  recover. 

Treatment. — There  is  no  general  method  of  treatment  for  tubercu- 
lous peritonitis  which  may  be  considered  justly  applicable  to  all  cases. 
Quite  a  proportion  are  known  to  recover  under  purely  medical  manage- 
ment, while  some  do  well  after  tapping  the  abdomen  and  removing  as 
much  as  possible  of  the  ascitic  fluid.  Others  demand,  on  the  merits  of 
the  case,  an  exploratory  ©jxTaiiun,  which  determines  at  once  the  nature 
of  the  subsequent  management.  At  .such  a  time  many  cases  are  chs- 
covered  to  be  entirely  inoperaWe. 

The  general  nicdiial  treatment  is  chiefly  that  of  superalimentation, 
with  due  regard  for  jiossible  digestive  disturbances,  rest,  hygienic  sur- 
roundings, and  attention  to  six'iial  s\  in])toms.  A  suitable  environment 
with  cheerful  surroundings,  ^dod  IucmI,  and  outdoor  facilities  is  of  prime 
importance.  Symptoms  shuuld  he  ivlicxcd,  if  possible,  as  they  ari.se. 
It  is  proper  to  resort  to  occasional  l,i.iii>iii,ii  if  demanded  for  the  comlort 
of  the  patient.  My  experience  with  this  ccmdition  has  been  somewhat 
limited,  but  sufficient  to  afford  satis! yini;  piodF  as  to  the  efficacy  of  rest. 
improved  nutrition,  and  absence  of  worr}'  in  the  effort  to  establish  con- 
valescence. I  have  in  mind  a  young  lady  in  whom  the  diagnosis  of 
peritoneal  tuberculosis  was  established  at  the  time  of  operation  for 
appencUcitis  in  lOOO,  |)revious  to  which  there  had  been  no  symptoms 
suggestive  of  ahdoiiiin.i!  disease.  For  several  years  following  the  oper- 
ation there  were  nn  cliuical  evidences  of  peritoneal  infection,  but  there 
developed  a  sliglit  pulmonary  involvement  witli  lar\-n,ncal  coni|)]ica,tions 
which  constituted  the  basis  for  her  comiiii;  (o  ( '(ihuailn.  In  the  midst 
of  a  most  excellent  nutrition,  ab.sence  of  cou,i;li.  cxpccidiatiDu.  and  lever, 
there  took  place,  five  years  following  her  initial  peritoneal  involvement, 
a  severe  rigor  and  sharp  elevation  of  temperature,  associated  with  intense 
abdominal  pain  and  vomiting.  Examination  of  the  abdomen  was  entirely 
negative,  save  for  a  very  slight  distention  and  general  stiffening  of  the 
abdominal  wall,  without  localized  tenderness.  With  recurring  chills 
and  continued  high  elevation  of  temperature,  increasing  abdominal 
distention,  and  beginning  general  tenderness,  the  abdomen  was  opened 
by  Dr.  Powers,  and  an  extensive  adhesive  tuberculous  peritonitis  was 
found.  The  serous  membrane  was  studded  throughout  l)Oth  its 
parietal  and  visceral  layers  with  small  tubcicle  deposits,  and  there  were 
multiple  adhesions  between  the  iMiisliiial  coils,  adjacent  organs,  and 
the  abdominal  wall.  The  case  is  of  csiiccial  iiilci-ostin  view  of  the  knowl- 
edge that  during  a  period  of  nian\'  years,  despite  an  extensive  patho- 
logic change  involving  the  wall  oi  the  pent al  ia\it\  and  its  con- 
tents, she  exhibited  no  symptoms  w  lia.iexcr  of  general  oi'  alidominal  dis- 
turbance. The  operation  was  indicated  as  an  exploratory  procedure, 
but  was  recognized  to  be  unavailing  as  a  therapeutic  measure,  on  account 
of  the  character  and  extent  of  peritoneal  infection. 

It  is  often  difficult  to  determine  satisfactorily  when  the  indications 
point  conclusively  toward  the  expediency  of  operati\c  inierfeicnce. 
An  exploratory  laparotomy  is  often  justified  after  failure  to  secure 
improvement  under  fom-  to  si\  weeks'  medical  management,  and  earlier 
if  the  patient  is  rapidlx'  declining-. 

In  acute  nulia.i\-  tuberculosis  the  patient  often  dies  before  the  symp- 
toms of  peritoneal  infection  are  apparent,  but  if  detected,  operation 
is  clearly  contraindicated  in  the  majority  of  cases.     All  cases  presenting 


412  COMPLICATIONS 

evidence  of  acute  intestinal  obstruction  should  be  accorded  the  possible 
benefit  to  be  derived  from  abdominal  section,  although  unusual  diffi- 
culties for  successful  results  are  presented  by  the  existence  of  the  numer- 
ous adhesions. 

Surgical  interference  avails  practically  nothing  in  cases  associated 
with  great  prostration  and  emaciation.  The  coexistence  of  tuberculous 
infection  in  other  parts  of  the  body  does  not  necessarily  contraindicate 
operation,  providing  the  general  condition  is  not  that  pf  extreme  pros'- 
tration.  The  nature  of  the  operative  interference  must  vary  in  indi- 
vidual cases.  A  simple  incision  is  sometimes  sufficient  and  often  highly 
satisfactory.  The  opening  of  the  abdominal  cavity  must  be  performed 
with  special  care,  on  account  of  the  possibility  of  intestinal  and  peri- 
toneal adhesions  immediately  beneath  the  site  of  the  incision.  It  is 
important  to  remove  as  much  of  the  contained  fluid  as  possible  in  order 
to  diminish  the  likelihood  of  reaccumulation.  It  is  rarely  advisable  to 
resort  to  drainage  or  flushing  of  the  abdominal  cavity.  In  general,  the 
less  meddlesome  the  interference,  the  more  satisfactor}-  the  results.  It 
is  unwise  to  attempt  to  break  up  adhesions  unless  to  relieve  intestinal 
obstruction  or  to  pro\'ide  opportunity  for  the  removal  of  the  contained 
fluid. 

It  is  important  to  remove,  when  possible,  local  foci  of  infection. 
This  applies  particularly  to  the  Fallopian  tubes,  the  appendix,  or  large 
cheesj'  ma.s.ses  in  the  omentum.  It  is  under  such  circumstances  that 
drainage  is  at  all  permissible,  and  even  then  but  for  a  short  period.  The 
danger  of  fecal  fistula  is  much  enhanced  in  those  cases  in  which  drainage 
is  employed. 

A  reaccumulation  of  fluid  does  not  in  itself  contraindicate  the  per- 
formance of  a  second  or  a  third  operation. 


SECTION    IV 
Glandular  Tuberculosis 


CHAPTER   LIX 

PATHOGENESIS  OF  GLANDULAR  INFECTION 

The  relation  of  the  lymphatic  system  to  the  development  and  spread 
of  tuberculosis  is  of  exceeding  interest.  The  distribution  of  bacilli  from 
a  primary  focus  of  infection  is  effected  in  very  many  instances  along  the 
lymphatic  and  circulatory  channels.  In  the  light  of  comparatively 
recent  investigation  it  is  known  that  tulierculosis  of  the  lymph-nodes, 
i.  e.,  the  cer\'ical,  tracheobronchial,  mesenteric,  and  retroperitoneal 
glands,  often  represent  primary  foci  of  infection.  An  initial  tubercle 
deposit  having  taken  place,  the  infection  is  conveyed  subsequently 
by  way  of  the  lymphatics  much  more  frequently  than  bj-  the  blood- 
vessels.    When  the  vascular  system  is  the  sole  carrier  of  bacilli,  the 


PATHOGENESIS    OF    GLANDULAR    INFECTION  413 

infection  of  various  tissues  is  found  to  occur  in  distal  portions  of  the 
body  in  sharp  contrast  to  the  direct  sequence  of  glandular  involvement 
which  ensues  when  the  microorganisms  are  chstributed  through  the 
lymphatic  channels.  In  the  latter  instance  the  proximal  gland  is  the 
first  enlarged,  the  subsequent  infection  throughout  the  immediate  chain 
of  lymphatics  exhibiting  a  progressively  diminishing  centrifugal  involve- 
ment. The  smaller  size  of  the  glands  in  proportion  to  their  distance 
from  the  original  infective  focus  illustrates  the  method  of  gradual  bacil- 
lary  invasion  along  the  lymphatic  route.  When  the  filtrative  capacity 
of  the  successive  glands  has  become  completely  overtaxed,  the  barriers 
are  removed,  which  hitherto  have  obstructed  to  a  degree  the  onward 
march  of  the  invaders.  The  progressive  advance  of  the  infection  is 
shown  not  only  by  the  gradually  <liiniiiisliing  size  of  the  glands,  but  as 
well  by  the  serial  stages  of  the  tiibcrciijous  process.  In  the  presence  of 
an  overpowering  invasion  of  l);u  illi  tlic  proximal  glands  in  their  effort  to 
perform  their  defensive  function  may  be  so  overwhelmed  as  to  result 
in  tissue  destruction.  Local  degenerative  processes  take  place.  The 
infected  gland  may  contain  caseous  foci  of  various  sizes,  or  become 
transformed  into  an  aliscess  containing  sterile  pus.  In  other  glands 
less  proximal  to  the  original  site  of  infection  the  battle  is  not  always  so 
completely  in  favor  of  the  invaders.  The  bacilli  may  be  held  as  prison- 
ers and  rendered  incapable  of  doing  further  daniatio  until  their  release 
is  secured  by  sufficient  reinforcement  to  o\cip(i\\cr  the  tissue-cells  con- 
stituting the  army  of  defen.se.  In  more  distal  iilands  the  enlargement 
may  be  so  slight  as  to  differ  liut  little  fi'imi  the  ikhiikiI  size,  and  yet  a 
minute  tuberculims  rcicus  may  be  iJicseiii  eithei-  in  the  interior  or  upon 
the  surface.  It  has  been  shiiwn  that  niil  <inly  are  (he  Ijacilli  in  many 
cases  held  in  comparative  security  within  the  conhnes  of  the  besieged 
glandular  citadel,  but  often  are  rendered  more  or  less  innocuous. 

Osier  has  referred  to  the  experiments  of  Arloing  as  indicating  a  degree 
of  degeneration  of  the  tuberculous  virus.  Rabbits  did  not  succumlj  to 
inocidation  from  a  lymphatic  gland,  although  a  positive  result  was 
obtained  with  guinea-pigs.  Lingard  demonstrated  a  quick  lymphatic 
infection  and  early  death  upon  inoculation  of  guinea-pigs  with  tubercle 
bacilli  from  the  lungs,  as  compared  with  a  delayed  lymphatic  enlarge- 
ment and  death  when  infected  from  scrofulous  glands. 

It  is  known  that  bacilli  from  glandular  structures  are  considerably 
less  virulent  than  those  from  almost  any  other-  tuberculous  focus  in  the 
body.  Whether  this  is  due  to  a  difference  in  the  infective  material  or  to 
certain  modifying  influences  of  the  lymphatic  glands  has  not  as  yet  been 
determined. 

Irrespective  of  the  distance  of  the  gland  from  the  original  site  of 
infection,  there  occasionally  ensues  such  a  degree  of  fibrous  tissue  pro- 
liferation as  to  produce  a  complete  protective  metamorphosis,  the  cap- 
sule becoming  enormously  thickened  and  the  septa  being  tough  and 
fibrous.  In  other  cases  a  true  calcification  may  result  from  the  abun- 
dant deposit  of  lime  salts.  Induration  of  the  glands  with  increasing 
fibroid  contraction  is  sometimes  stimulated  by  the  presence  of  mineral 
dust.  This  is,  of  course,  particularly  true  of  the  tracheobronchial  glands, 
which  become  densely  pigmented  and  even  gritty  from  the  inhalation 
of  particles  of  palpable  dust. 

In  view  of  the  involvement  of  glands  nearest  to  the  port  of  entry  of 
infective  material,  it  has  followed  that  given  glandular  systems  are  jound 


414  COMPUCATIONS 

to  drain  certain  tributary  areas.  Thus  the  glands  of  the  neck,  including 
the  auricular,  cervical,  submaxillary,  and  even  the  supraclavicular  and 
infraclavicular,  constitute  the  lymphatic  filters  of  the  nose,  throat, 
tonsils,  palate,  mouth,  ears,  and  orbit,  as  well  as  the  skin  of  the  face  or 
head.  There  are  both  superficial  and  deep  glands  of  the  neck.  The 
latter  constitute  a  chain  extencUng  from  the  skull  to  the  thorax,  along 
the  sheath  of  the  carotid  and  juiiular,  establisliing  a  communication 
with  the  thoracic  and  axillary  ;:hui.l>,  as  well  as  with  the  corresponding 
set  of  the  opposite  side.  The  deeper  liroup  especially  serves  as  a  reser- 
voir for  the  lymphatics  of  the  tonsils,  mouth,  nose,  eye,  and  larynx. 
Glandular  enlargement  is  usually  noted  in  the  re^on  of  the  angle  of  the 
jaw  before  a  downward  extension  along  the  neck  is  recognized. 

In  like  manner  the  tracheobronchial  glands  are  the  reservoir  for  the 
lymphatics  from  the  lungs,  pleura,  and  surrouncUng  parts.  These 
glands  are  located  near  the  bifurcation  of  the  trachea,  and  are  more 
numerous,  as  a  rule,  upon  the  right  than  upon  the  left  side.  A  chain  of 
smaller  glands  lie  in  close  proximity  to  the  left  recurrent  larjTigeal  nerve 
in  its  course  under  the  aorta,  and  another  along  the  right  in  its  passage 
under  the  subclavicular  artery.  Glands  accompany  the  smaller  lym- 
phatics along  the  primary  divisions  of  the  bronchi,  and  are  found,  accord- 
ing to  Quain,  at  the  bifurcation  of  the  branches  of  the  pulmonary  arter}-. 
There  is  some  cUfference  of  opinion  regarcUng  the  intercommunicabilitj'- 
of  the  lymphatics  of  the  neck  and  chest.  Barety  is  quoted  by  Dr.  J.  N. 
Hall  as  authority  for  a  relationship  between  the  bronchial  and  supracla- 
vicular glands,  upon  the  basis  of  a  connecting  link  esta])lished  by  a  group 
of  glands  behind  the  sternoclavicular  articulation.  Volland  ascribes  the 
origin  of  many  cases  of  pulmonary  tuberculosis  to  an  infected  cervical 
gland.  Cornet  calls  attention  to  the  fact  that  while  involvement  of  the 
cervical  glands  may  occasionally  take  place  by  extension  upward  from 
the  bronchial  glands,  nevertheless,  in  piilmonary  tuberculosis  of  children, 
the  glands  of  the  neck  are  rarely  chseased.  In  case  of  a  simultaneous 
involvement  of  the  cervical  and  bronchial  glands  he  chooses  to  assume 
a  separate  focus  of  infection  for  the  two  groups. 

The  mesenteric  or  retroperitoneal  glands  serve  as  filters  for  the  intes- 
tinal tract,  the  peritoneum,  and  sometimes  the  genito-urinary  apparatus. 
Less  interest  attaches  to  tuberculosis  of  lymphatic  glands  of  other  parts 
of  the  body  on  account  of  the  comparatively  slight  opportunity  of  infec- 
tion through  the  skin. 

In  defining  certain  sets  of  glands  as  the  drainage  basin  for  a  given 
tributary  area,  it  must  not  be  assumed  that  a  primary  focus  of  tuber- 
culosis necessarily  exists  within  this  region.  As  a  matter  of  fact,  the 
majority  of  cases  of  glandular  tuberculosis,  especialh'  in  children,  are 
of  primary  rather  than  secondary  development,  as  has  been  clearly 
established  through  the  recognition  of  a  macroscopically  intact  mucous 
membrane. 

Ravenel  has  shown  by  experiments  upon  doi:s  that  the  liacilli  may 
pass  through  an  intact  intestinal  wall  directly  t"  the  in.'seiiteric  lym- 
phatic glands.  Sydney  Martin  has  also  demon.-i  rated  that  the  bacilli 
may  permeate  a  healthy  intestinal  mucosa  and  gain  access  to  the  mesen- 
teric glands.  Cornet.  Orth,  Klebs,  Baumgarten,  \\'alsham,  and  Litterer, 
as  well  as  Calmette  and  his  followers,  have  concluded,  as  the  results  of 
their  own  experiments,  that  the  tubercle  bacillus  often  secures  a  port  of 
entry  through  a  normal   mucous  membrane.     Benda  and   Hamilton 


PATHOGENESIS    OF    GLANDULAR    INFECTION  415 

voice  the  consensus  of  opinion  that  the  point  of  invasion,  by  virtue  of 
local  concUtions,  may  be  an  unfavorable  site  for  tuberculous  develop- 
ment, and  yet  the  bacilli  be  conveyed  to  a  soil  which  is  more  receptive. 
It  is  known  that  tuberculous  glands  are  found  with  great  frequency  at 
autopsy  among  children  in  whom  there  are  no  other  discoverable  lesions. 

Repeated  investigations  have  demonstrated  the  role  of  the  tonsils 
and  adenoid  vegetations  in  affording  a  port  of  entry  for  the  tubercle 
bacillus,  even  in  the  absence  of  local  inflammatory  changes.  The  deep 
crypts  in  the  tonsillar  tissues  constitute  an  infection  atrium  from  which 
the  further  progress  of  the  bacilli  uldii.i;-  tlic  1\  inpliutic  channels  to  neigh- 
boring glands  is  practically  unimpeded.  ( >ii  the  other  hand,  tubercle 
bacilli  have  been  shown  to  be  iiicsini  in  the  tonsils  and  in  ade- 
noid growths  despite  failure  to  discover  tul.ierculous  infection  in  other 
parts  of  the  body.  The  adenoids  have  been  found  tuberculous  some- 
what more  frequently  than  the  tonsils,  undoubtedly  on  account  of  the 
greater  narrowing  of  the  respiratory  passage  and  the  increased  oppor- 
tunities afforded  for  tubercle  deposit. 

Fifteen  per  cent,  of  all  adenoids  were  found  tuberculous  by  Lartigau, 
while  Robertson  reports  bi.t  S  ].cr  cent,  of  hypertrophied  tonsils  to  be 
infected.  Lermoyez,  as  a  re.'-i'.lt  ol  inonihition  experiments  upon  guinea- 
pigs,  stated  the  proportion  of  tubcri  uio^is  in  adenoids  to  be  20  per  cent, 
and  in  hypertrophied  tonsils  I'.i  per  cent.  Wood  reports  that  out  of  a 
total  of  1671  adenoids  or  tonsils  examined  for  tuberculosis,  without 
evidence  of  tuberculous  involvement  elsewhere,  a  positive  result  was 
obtained  in  88,  or  about  5  per  cent.  The  presence  of  tul icicle  bucilli 
in  the  tonsils  and  adenoid  growths  of  apparently  healtli\-  iiidi\iduals 
suggests  the  probability  of  their  not  infrequent  passage  to  the  lyniph.'itic 
glands,  producin.';  therein  a  primary  seat  of  tuberculous  infection. 
Jacobi  has  held  to  the  opinion  for  years  that  infection  of  the  cervical 
nodes  occurs  much  less  frequently  through  the  tonsils  or  adenoids  than 
through  the  medium  of  the  lymph-follicles  in  the  nose  and  pharynx. 
It  must  be  admitted  that  enlargement  of  the  cervical  lymph-glands 
follows  inflammatory  processes  in  the  nose  and  nasopharynx  more 
quickly  and  more  frequently  than  an  infection  confined  solely  to  the 
tonsils. 

It  has  been  shown  conclusively  that  when  the  lungs  are  also  diseased, 
the  pulmonary  involvement  in  the  vast  majority  of  cases  is  secondary 
to  tuberculosis  of  the  bronchial  glands. 

The  precise  manner  in  which  the  bronchial  glands  become  subject 
to  tuberculous  infection  remains  a  somewhat  disputed  point,  although 
the  preponderance  of  evidence  suggests  an  invasion  of  the  body  by 
bacilli  through  the  digestive  .system.  Some  maintain  that  the  essential 
consideration  is  the  aspiration  of  the  bacilli  into  the  bronchial  tract  and 
their  passage  through  an  intact  bronchial  mucosa.  Behring  asserts 
that  the  infection  takes  place  originally  through  the  intestine  rather 
than  by  inspired  air.  He  believes  the  infant's  milk  to  be  the  chief 
source  of  tuberculosis  in  childhood  as  well  as  in  adult  life.  He  asserts 
that  the  foci  of  infection  thus  engendered  remain  latent  for  varjdng 
periods  of  time  until  individual  resistance  is  sufficiently  lowered  to  per- 
mit their  active  development.  Behring's  \'iews  have  been  cUscussed 
in  connection  with  the  method  of  infection  through  the  alimentary 
canal,  as  have  also  the  experimental  observations  of  others  who  have 
demonstrated  the  ease  with  which  tubercle  bacilli  may  penetrate  the 


416  COMPLICATIONS 

intestinal  wall  without  visible  lesion  and  gain  ready  access  to  the 
glandular  structures.  The  later  researches  of  Calmette  and  Guerin, 
Engel  and  Schlossman,  have  shown  the  passage  of  bacilli  through  an 
intact  mucous  membrane  to  the  mesenteric  and  bronchial  glands  of 
animals,  and  their  early  appearance  in  the  thoracic  duct  and  pulmonary 
artery.  Behring"s  contention  that  the  permeability  of  the  intestinal 
wall  is  much  greater  in  infancy  on  account  of  the  more  delicate  structure 
is  of  much  interest.  Differences  in  the  passage  of  microorganisms 
through  the  wall  of  the  intestine  at  varous  ages  were  demonstrated  by 
experiments  upon  animals.  Tubercle  bacilli  were  fed  to  guinea-pigs 
with  the  result  that  only  the  very  young  became  tuberculous,  enlarge- 
ment of  the  glands  of  the  neck  being  noticed  even  while  the  general 
concUtion  appeared  entirely  normal.  Ravenel,  on  the  other  hand, 
has  recently  introduced  tubercle  bacilli  with  the  food  into  the  stomach 
of  two  monkeys  and  one  cow,  producing  tuberculosis  of  the  bronchial 
glands  and  lungs  without  mesenteric  or  intestinal  lesions.  Some  inves- 
tigators have  been  unable  to  produce  tuberculosis  of  the  lungs  or  bron- 
chial glands  after  carefully  conducted  inhalation  experiments.  There 
can  be  no  doubt  as  to  the  primary  involvement  of  the  bronchial  lymph- 
atic nodes  in  little  children.  In  the  light  of  all  the  evidence  presented 
it  would  seem  that  it  must  remain  sub  judice  whether  in  individual  cases 
the  initial  infection  is  purely  respiratory  or  intestinal.  It  has  been 
demonstrated  beyond  question  that  the  infection  may  pursue  either  of 
these  routes  in  cUfferent  cases. 

Apropos  of  experimental  investigation,  it  may  be  stated  that  the 
important  consideration  in  this  connect  ion  is  not  altogether  the  deter- 
mination of  the  exact  pathogenesis  of  glandular  infection,  but  rather 
the  fact  that,  by  whatever  route,  glandular  tuberculosis  occurs  with 
great  frequency  in  little  children. 

Opinions  differ  concerning  the  significance  of  the  family  history. 
Statistics  have  been  cited  both  to  demonstrate  and  to  deny  the  influ- 
ence of  heredity  as  an  etiologic  factor.  Lowered  resistance  may  take 
place  among  children  of  healthy  parents,  wlrile  others  with  more  or 
less  inherent  predisposition  to  disease  may  thrive  by  virtue  of  especially 
favorable  concUtions.  A  positive  family  history  of  tuberculosis  while 
not  to  be  regarded  as  a  factor  of  great  import,  must,  neverthele-ss,  be 
conceded  to  possess  some  practical  .significance.  The  reasons  for  a 
greater  frequency  of  glandular  tuberculosis  in  children  than  in  adults 
are  found  in  the  comparative  ease  with  wliich  the  delicate  mucous  mem- 
branes are  traversed  by  bacilli,  and  the  increased  facilities  with  which 
the  germs  are  conveyed  through  the  open  permeable  lymph-spaces.  In 
addition  may  be  cited  certain  accessory  features  which  increase  the 
likelihood  of  infection  and  to  a  material  extent  diminish  inchvidual 
resistance.  The  influence  of  enlarged  tonsils  and  adenoids  in  encroach- 
ing upon  the  normal  respiratory  passages  and  ofTeiing  a  site  for  the 
depo.sit  of  bacteria  has  been  mentioned.  Infants  being  directly  depen- 
dent upon  the  care  of  others  are  subjected  to  increaseil  danger  of  expo- 
sure to  tuberculous  infection.  The  child  is  often  upon  the  floor,  and 
thus  is  brought  in  closer  contact  with  the  bacilli,  which  contaminate  the 
carpets  and  rugs.  The  vitality  of  infants  is  frequently  reduced  by 
digestive  chsorders  and  catarrhal  disturbances,  inferior  ventilation,  and 
improper  hygienic  concUtions.  Irrespective  of  the  causes,  the  fact 
remains  that  tuberculosis  is  exceedingly  common  in  childhood  and  that, 


PATHOGENESIS    OF    GLANDULAR    INFECTION  417 

in  the  great  majority  of  cases,  the  lymphatic  glands  constitute  the  pri- 
mary focus  of  infection.  The  accuracy  of  this  statement  is  substantiated 
by  the  reports  of  numerous  observers.  Medical  literature  abounds  in 
statistical  analyses  as  to  the  frequency  of  tuberculosis  of  the  lymph- 
nodes  in  childhood.  For  the  purposes  of  illustration  it  is  well  to  refer 
briefly  to  some  of  these  investigations,  though  any  attempt  to  quote  at 
length  would  seem  superfluous. 

\'olland,  Beruti,  Balmann,  and  Wohlgemuth,  as  the  result  of  an 
examination  of  very  many  children,  report  the  cervical  lymphatic  glands 
to  be  enlarged  in  the  proportion  of  from  81  per  cent,  to  96  per  cent., 
according  to  Pottenger.  The  reports  of  other  observers  as  to  the  char- 
acter of  the  cervical  enlargement  in  children  would  indicate  that  nearly 
two-thirds  are  tuberculous.  Cornet's  analysis  of  the  autopsy  records 
of  the  Berlin  Pathological  Institute  for  a  period  of  fifteen  years  shows 
not  a  single  case  of  tuberculosis  out  of  486  cases  from  birth  to  the  end  of 
the  first  month;  from  two  to  three  months,  6  per  cent,  of  the  cases;  from 
three  to  six  months,  10.5  per  cent. ;  from  six  to  nine  months,  17  per  cent. ; 
from  nine  to  twelve  months,  27.7  per  cent.;  from  one  to  two  years,  26.6 
per  cent.;  from  two  to  three  years,  29.6  per  cent.;  from  three  to  four 
years,  31.8  per  cent.;  from  four  to  five  years,  22.4  per  cent.  Several 
other  observers,  notably  Miiller,  Babes,  Heubner,  Newmann,  Still,  Hand, 
iSimonds,  Schever,  Bolz,  Jacobi,  and  Holt  have  reiioitcd  statistics  not 
especially  dissimilar  to  these  results,  the  proportion  raimini:.  in  <  hildfcn 
up  to  five  years,  from  22  to  40  per  cent.  Forei,!in  statistics  ((inccruing 
the  prevalence  of  glandular  tuberculosis  show  higher  percentages  than 
&re  obtained  in  this  country.  Nearly  all  observers  agree  that,  in  the 
majority  of  cases,  the  pathologic  evidence  points  to  involvement  of  the 
lymphatic  glands  as  the  primary  foci  of  infection,  the  lungs  being 
secondarily  diseased.  In  autopsies  upon  tuberculous  children  the  bron- 
chial glands  are  almost  always  found  tuberculous. 

Cornet  quotes  the  statistics  of  Steiner  and  Neureutter,  who  report 
tuberculosis  of  the  lymph-glands  in  299  out  of  302  autopsies.  The  bron- 
chial glands  were  tuberculous  in  286  of  these  cases.  He  also  refers 
to  the  report  of  Rilliet  and  Barthez,  who  found  the  lymphatic  glands 
tuberculous  in  248  cases  out  of  a  total  of  312  autopsies  upon  tuberculous 
subjects.  Northrup's  report  of  bronchial  glandular  involvement  in 
every  instance  in  a  series  of  ]2.i  aiitniipics  has  been  widely  quoted.  The 
same  results  were  obtained  !)>•  .Xoithiup  in  a  second  series  of  125  cases  in 
the  New  York  Foundling  Hosiiital.  llojt  reports  119  ca.ses  in  which  the 
bronchial  glands  were  tuberculous  in  every  instance.  In  115  autopsies 
Hand  reports  the  bronchial  glands  involved  in  81.7  per  cent.;  the  lungs, 
in  78  per  cent.  Both  Steffen  and  Bulius  found  the  lymphatic  glands 
infected  in  nearly  every  autopsy  reported  upon  tuberculous  patients. 
All  observers  agree  that  the  tracheobronchial  glands  are  involved  more 
frequently  than  any  others,  with  the  cervical  system  next  in  order. 
Haushalter,  in  a  report  upon  the  results  of  78  autopsies  performed  upon 
children  who  had  died  of  acute  miliary  tuberculosis,  states  that  tuber- 
culosis of  the  mediastinal  glands  was  found  in  all  but  4  cases.  Enlarged 
bronchial  glands  from  individuals  exhibiting  no  evidence  of  tuberculosis 
have  been  found  by  inoculation  experiments  to  be  infective  to  animals. 
Allusion  has  been  made  to  the  experiments  of  Pizzini  and  others,  who 
reported  positive  inoculation  results  in  a  large  proportion  of  cases. 

Pizzini,  after  inoculating  animals  with  the  bronchial  glands  of  40 
27 


418  COMPLICATIONS 

patients,  found  42  per  cent,  tuberculous.  It  is  interesting  to  note  that 
injection  of  the  cervical  glands  from  the  same  subjects  was  followed 
by  tuberculosis  in  but  2  per  cent,  of  the  animals,  while  none  showed 
evidence  of  infection  with  inoculation  of  the  mesenteric  glands.  Loomis 
has  demonstrated  by  inoculation  experiments  with  bronchial  glands 
the  existence  of  tuberculo.sis  which  had  previously  been  unrecognized. 
Bertalot  discovered  tidjercidosis  of  the  bronchial  glands  in  20  out  of  24 
children  w-ho  had  tiled  of  tuberculous  meningitis.  Both  Reiner  and 
Henoch  report  tuberculosis  in  nearly  all  cases  of  tubercidous  meningeal 
infection. 

The  symptomatic  manifestations  of  enlarged  tuberculous  glands 
vary  according  to  their  location.  The  clinical  picture  of  cervical  tuber- 
culous adenitis  is  quite  different  from  that  of  tabes  mesenterica. 
Enlargement  of  lironchial  glands  often  produces  still  another  character- 
istic grouping  of  symptoms,  as  well  as  definite  physical  signs.  It  is  well, 
therefore,  to  consider  separately  the  clinical  features  of  tuberculosis  of 
the  various  lymph-nodes. 


CHAPTER   LX 
TUBERCULOSIS  OF  THE  CERVICAL  GLANDS 

This  form  is  very  common  among  little  children,  and  not  infre- 
quently occurs  in  young  adults.  It  exists  occasionally  in  middle  life. 
Local  conditions  favoring  its  development  are  hypertrophied  tonsils, 
chronic  catarrhal  processes  in  the  nose,  nasopharynx,  and  phar3Tix, 
eczema  of  the  scalp,  otitis  media,  and  disease  of  the  gums  or  teeth. 
Tuberculous  glands  of  the  neck  often  accompany  a  beginning  conva- 
lescence from  measles,  whooping-cough,  and  sometimes  influenza.  Dur- 
ing the  past  few  years  I  have  noted  an  increasing  number  of  instances 
of  enlarged  glands  near  the  angle  of  the  jaw  in  children  following  influ- 
enza and  simple  tonsillitis.  Many  of  these  cases  were  at  first  regarded 
as  belonging  to  the  category  of  ordinary  glandular  fever,  but  their 
chronicity  suggests  the  probability  of  a  tuberculous  infection. 

Among  general  conditions  predisposini:  to  tlio  development  of  tuber- 
culosis of  the  cervical  glands  may  be  mentioned  in<iiiricient  ventilation, 
improper  and  deficient  food,  poor  surroundinu,.^,  and  iiiade(|uate  clothing. 
An  important  factor  is  the  reduced  vitality  incident  to  disturbances  of 
digestion  and  nutrition. 

TuI)erculous  cer\ical  adenitis  may  be  unilateral  or  bilateral,  although 
in  the  hitter  event  the  process  is  usually  more  pronounced  upon  one  side. 
An  essenii.i!  ( li.naiteiistic  of  the  condition  is  the  chronicity  of  its  course. 
The  <iiisrt  nia\-  lie  iu-idious  to  a  degree,  the  attention  being  first  attracted 
by  the  aciidenlal  ilisco\ery  of  a  few  small,  hard,  rountled  nodules,  which 
are  usually  painless  and  freely  movable  under  the  skin.  Occasionally, 
however,  the  beginning  involvement  is  more  abrupt,  especially  if  follow- 
ing an  attack  of  measles,  whooping-cough,  diphtheria,  ton.sillitis,  scarlet 
fever,  or  influenza.     Under  these  circumstances  the  glandular  enlarge- 


TUBERCULOSIS    OF    THE    CERVICAL    GLANDS  419 

ment  assumes  the  appearance  of  a  brawny,  diffused  inflammatory  mass, 
which  is  often  tender  and  adherent  to  subjacent  structures. 

Cases  with  insidious  onset  may  sometimes  persist  for  years  without 
the  knowledge  of  the  patient  or  parents,  the  enlargement  being  impercep- 
tible upon  ordinary  inspection,  but  easily  recognized  upon  palpation. 

The  submaxillary  group  of  glands  are  more  frecjuently  involved,  but 
it  is  very  common  to  detect  a  chain  of  small  nodules  extencUng  along  the 
anterior  or  the  posterior  border  of  the  sternocleidomastoid  muscle. 
Tuberculous  cervical  glands  occur  more  often  in  the  upper  portion  of  the 
neck  than  at  the  base,  in  contradistinction  to  the  glandular  enlargement 
of  Hodgkin's  disease.  It  does  happen  occasionally,  however,  that  the 
glands  above  the  clavicle  and  in  the  posterior  cervical  triangle  become 
tuberculous  in  connection  with  a  similar  involvement  of  the  axillary 
glands. 

In  the  insidious  form  of  cervical  adenitis  the  diseased  glands  are 
isolated,  firm,  sinooih.  ^lc)bvllar  or  ovoid  in  outline,  devoid  of  pain,  and 
more  or  less  moxuMc  under  the  skin.  In  the  acute  cases  the  glands 
are  more  swollen,  often  irregular  in  shape,  and  even  if  painless  and  hard, 
are,  as  a  rule,  less  movable.  They  frequently  become  fixed  to  the  sur- 
rounding parts,  though  the  skin  is  not  always  adherent.  As  the  inflam- 
mation increases  still  more  the  .glands  appear  to  be  somewhat  fused, 
forming  a  large,  brawny  or  knotted  swelling  which  is  sometimes  cUs- 
tinctly  painful  and  tender.  As  sujipuration  takes  place  the  swelling 
increases,  fluctuation  is  detected,  the  skin  Ix'comes  fixed  to  the  mass, 
and  localized  bulging  and  redness  develop.  The  skin  is  often  very  thin 
over  the  area  of  suppuration. 

^  Cases  attended  by  abscess  formation  usually  exhibit  elevation  of 
temperature,  although  fever  is  by  no  means  constant.  It  is  often  present 
despite  the  absence  of  pus,  particularly  when  the  glands  are  of  large 
size.  The  patients  are  usually  anemic  and  poorly  nourished.  The 
scrofulous  type  of  face  has  frequently  been  described  as  consisting  of 
thick  lips,  coarse  features,  broad  nose,  muddy  complexion,  and  generally 
heavy  aspect. 

The  course  of  the  disease  is  slow  and  unsatisfactory  in  a  large  number 
of  cases,  but  a  fatal  termination  rarely  supervenes.  Meningeal  extension 
is  much  less  frequent  than  from  tuberculosis  of  the  bronchial  glands. 
That  general  miliary  involvement  is  not  more  common  is  somewhat 
difficult  to  explain.  Although  tuljerculous  glands  of  the  neck  may  persist 
for  years  in  individuals  perfectly  well  in  other  respects,  the  fact  remains 
that  they  constitute  an  ever  pos.sible  source  of  infection.  The  constant 
menace  to  life  resulting  from  the  presence  of  InHignilicant  and  apparently 
harmless  nodules  in  the  neck  is  illustrated  by  the  following  case.  I  have 
recently  seen  a  young  man  with  general  miliary  t>il>erculosis,  the  origin 
of  which  is  undoubtedly  to  be  traced  to  a  small  gland  in  the  neck  the 
size  of  a  small  walnut,  of  one  and  one-half  ycais'  duration.  On  account 
of  the  general  invasion,  with  characteristic  .■iniii-  l,ii yugeal  involvement, 
the  patient  has  been  advised  to  return  to  his  Ikhiic.  Fig.  Ill,  repro- 
duced from  a  photograph,  shows  not  only  the  small  .size  of  the  gland, 
which  is  almost  unnoticeable  unless  the  head  is  inclined  to  the  opposite 
side,  but  also  the  excellent  nutrition,  which  thus  far  has  been  but  little 
affected. 

Diagnosis. — The  special  feature  of  diagnosis,  aside  from  the  exis- 
tence of  tuberculosis  elsewhere,  relates  to  a  differentiation  from  the 


420 


COMPLICATIONS 


enlargement  of  simple  inflammatory  adenitis,  lymphatic  leukemia,  and 
Hodgkin's  disease. 

The  persistence  of  the  mass  without  acute  inflammatory  signs,  par- 
ticularly in  the  absence  of  such  exciting  causes  as  the  acute  infectious 
diseases  or  poor  teeth,  sufficiently  characterizes  the  condition  to  exclude 
a  simple  glandular  aljscess. 

The  absence  of  loiikdcytosis,  \\liic!i  always  accompanies  lymphatic 
leukemia,  is  easily  ilctcriiiinccl  l>y  ihc  ixammation  of  the  blood.  It  is 
sometimes  difficult  t<>  iliffercntiate  aicmatcly  between  lymphatic  tuber- 
culosis and  the  lymphadenoma  of  Hotlgkin's  disease.  In  general  it 
may  be  stated  that  in  the  latter  condition  suppuration  rarely  takes 
place,  and  the  glands  are  usually  firmer,  harder,  and  less  tender  than 
in  tuberculosis.  Although  they  may  attain  large  size,  they  are  more 
often  discrete  and  less  adherent  to  one  another  and  to  surrounding  parts. 


1.'.  tulluwed  by  le 


They  rarely  are  fused  into  large  ma.s.ses,  but  tend  rather  to  preserve 
their  individuality,  and,  as  a  rule,  are  somewliat  movable  under  the  skin. 
The  condition  is  perhaps  less  frequent  in  children,  although  it  may  occur 
at  any  age.  In  Hodgkin's  disease  the  site  of  the  enlargement  is  usually 
in  the  lower  part  of  the  neck,  while  the  reverse  is  true  in  tulierculosis. 
The  tuberculin  reaction  is  not  always  perfectly  reliable,  as  it  has  been 
shown  that  the  two  conditions  m.-xy  coexi.st.  Fever  may  be  present  in 
either  case.  It  is  probable  that  the  ophthalmotuberculin  test  may  be 
of  value  when  the  diagnosis  is  obscure.  Several  cases  have  been  reported 
presenting  the  clinical  picture  of  Hodgkin's  disease,  which  were  found  to 
be  tuberculous  at  autopsy.  Sternberg  and  Musser  are  quoted  by  James 
as  of  the  opinion  that  the  glandular  enlargement  of  Hodgkin's  cUsease 
is  tuberculous  in  character,  thus  explaining  the  irregular  fever  which  so 
often  is  pre.sent.  Dr.  D.  M.  Reed  and  Dr.  W.  B.  James,  however,  report 
negative  results  from  inoculation  experiments  and  careful  study  of  the 


TUBERCULOSIS    OF    THE    CERVICAL    GLANDS  421 

glands  in  a  number  of  cases  of  Hodgkin's  disease  exhibiting  temperature 
elevation. 

The  difficulties  of  exact  differential  diagnosis  between  the  two  con- 
ditions is  shown  by  a  case  which  has  been  under  my  observation 
something  over  ten  years.  The  patient  was  thirty  years  old,  of  negative 
family  history,  and  previous  good  health  when  he  consulted  me  with 
reference  to  a  rapidly  growing  mass  in  the  left  neck,  slightly  above  the 
clavicle.  The  enlargement  had  been  of  but  three  or  four  weeks'  dur- 
ation, but  was  associated  with  much  general  weakness,  extreme  pallor, 
and  emaciation.  The  glands  were  hard,  perfectly  discrete,  painless, 
and  more  or  less  movable,  presenting  no  resemblance  to  a  brawny 
swelling.  There  was  no  redness,  adhesion  of  the  skin,  or  fever.  The 
injection  of  tuberculin  for  diagnostic  purposes  was  attended  by  a 
negative  result.  The  glands  continued  to  increase  in  size  until  the 
patient  was  unable  to  wear  a  collar.     A  second  group  of  glands  became 


enlarged  back  of  the  angle  of  the  jaw,  and  presented  the  same  charac- 
teristics. There  developed  a  slight  involvement  upon  the  right  side  of 
the  neck,  in  the  left  axilla,  and  in  each  groin.  The  spleen  became  dis- 
tinctly palpable.  The  examination  of  the  blood  was  negative.  The 
patient  rapidly  became  ])rost rated  and  was  forced  to  remain  in  bed. 
The  diagnosis  of  Hodgkin's  di.sease  was  made  and  later  indor.sed 
unequivocally  by  Drs.  Bergtold,  Powers,  Whitney,  and  others.  The 
family  were  informed  as  to  the  hopeless  nature  of  the  condition  and  a 
comparatively  speedy  termination  was  expected.  There  soon  developed 
an  intense  bronzing  of  the  skin  of  the  entire  body,  with  progressive 
glandular  enlargement.  Almost  daily  vomiting  prevented  recourse  to 
superalimentation.  The  treatment  consisted  simply  of  rest,  very  large 
doses  of  Fowler's  solution,  and  bone-marrow.  The  downward  progress 
of  the  disease  gradually  became  arrested,  but  the  patient  remained  in 
bed  for  a  period  of  many  months,  followed  by  a  life  of  invalidism  for 
nearly   two  years.      The   glands    became    slowly   and   almost   imper- 


422  COMPUCATIONS 

ceptibly  reduced  in  size,  as  also  the  Spleen.  The  bronzing  of  the 
integument  persisted  for  three  or  four  years  and  was  accompanied  by  a 
remarkable  thickening  of  the  skin  of  the  hands  and  feet,  with  pronounced 
peeling  at  short  inter\'als.  Two  years  after  the  initial  onset  the  patient 
was  seen  by  Dr.  Coley,  of  New  York,  who  concurred  in  the  previous 
diagnosis.  During  the  ensuing  years  several  relapses  of  a  milder  nature 
have  taken  place.  Since  the  introduction  of  the  a--rays  their  employ- 
ment has  been  resorted  to  periodically  in  this  case  with  considerable 
benefit.  At  the  present  time  the  patient  exhibits  all  the  external  appear- 
ances of  perfect  health ,  and  the  enlarged  glands  of  the  neck  have  almost 
entirely  disappeared.  There  remain  two  nodules  of  moderate  size, 
recognized  upon  inspection,  in  the  upper  left  neck,  and  several  small 
palpable  masses  in  the  lower  right,  just  above  the  clavicle.  There  is, 
moreover,  dulness  with  diminished  intensity  of  the  respiratory  sounds  at 
each  apex,  extending  nearly  to  the  second  rib.  As  a  result  of  prolonged 
x-ray  exposures  a  well-defined  telangiectasis  has  appeared  upon  each 
side  of  the  neck.  Fig.  112  repre.sents  the  photograph  of  the  neck  just 
taken,  which  is  of  interest  in  connection  with  the  skiagraph,  Fig.  48, 
showing  well-marketl  apical  involvement  of  the  lung.  In  plate  11 
is  shown  the  present  telangiectatic  condition  upon  each  side,  and  the 
two  visible  nodules  upon  the  left.  It  would  appear  that  no  case  could 
present  a  clearer  picture  of  Hodgkin's  disease,  and  yet,  in  the  light  of 
the  improvement  and  the  present  physical  signs,  despite  a  negative 
tuberculin  test,  the  conclusion  is  forced  that  the  original  glandular 
infection  was  of  a  tuberculous  nature. 


CHAPTER   LXI 


TUBERCULOSIS  OF  THE  MEDIASTINAL  AND  MESEN- 
TERIC GLANDS 

MEDIASTINAL  GLANDS 

The  clinical  manifestations  of  tuberculous  enlargement  of  the 
tracheobronchial  glaiuls  are  extremely  varied  in  character,  there  being 
no  direct  relation  between  the  symptoms  and  physical  signs.  It  fre- 
quently happens  that  pronoimced  symptoms  ari.se  suggesting  the 
probability  of  enlarged  mediastinal  glands,  with  an  entire  absence  of 
objective  signs.  In  other  cases  the  physical  evidences  of  tuberculous 
glandular  enlargement  may  be  so  definite  as  to  permit  the  recognition 
of  a  distinct  mass  without  the  exhibition  of  symptoms.  The  condition 
is  more  common  in  little  children  than  at  any  other  age;  typical  cases  in 
young  adults  are  not  infrequent. 

Both  the  symptoms  and  signs  are  largely  dependent  upon  the  location 
of  the  glandular  enlargement,  the  degree  of  compression  exerted  upon 
contiguous  parts,  with  consequent  functional  disturbance,  the  possible 
perforation  through  an  intervening  wall  into  adjacent  structiu-es,  and 
the  extension  of  the  infection  through  the  l.ymphatics  into  neighboring 


il 


12 


|2 


"si 


TUBERCULOSIS    OF    THE    MEDIASTINAL    AND    MESENTERIC    GLANDS     423 

The  usual  location  of  the  tuberculous  glands  has  been  stated  to  be  in 
the  neighborhood  of  the  bifurcation  of  the  trachea  in  the  posterior  por- 
tion of  the  mediastinal  space.  Attention  has  been  called  to  their  fre- 
quent proximity  to  the  left  recurrent  laryngeal  nerve.  Among  neighbor- 
ing structures  apart  from  the  trachea  and  bronchi  are  the  pulmonary 
artery,  the  superior  vena  cava,  the  aorta  with  its  branches,  the  pulmo- 
nary veins,  the  pneumogastric  and  phrenic  nerves,  and  the  esophagus. 
Well-defined  symptoms  may  result  from  compression  of  any  of  these 
parts  to  a  greater  or  less  degree  by  a  mass  of  tuberculous  glands.  The 
nature  of  the  symptoms  varies  according  to  the  particular  point  of 
compi'ession  upon  any  of  these  structures.  The  pressure  symptoms 
of  perhaps  more  frequent  occurrence  relate  to  the  trachea  and  primary 
bronchi.  If  compres.sion  be  exerted  upon  the  trachea  alone,  alarming 
dyspnea  may  supervene.  This  is  often  associated  with  a  violent  dry 
paroxysmal  cough,  not  very  dissimilar  to  that  of  pertussis.  In  other 
cases  the  cough  and  respiration  simulate  asthma  to  some  extent.  The 
severity  of  these  symptoms  is  not  altogether  dependent  upon  the  degree 
of  compression.  1  well  remember  the  case  of  an  adult  who  exhibited 
most  distressing  dyspnea,  with  almost  incessant  paroxysmal  cough  and 
wheezing  respiration.  There  was  found  at  autopsy  but  slight  compres- 
sion from  a  glandular  mass  adherent  to  the  trachea,  penetrating  the 
posterior  wall  and  protruding  within  the  lumen  to  the  size  of  a  small 
pea. 

The  physical  signs  of  tracheal  compression  consist  primarily 
of  a  diminished  respiratory  excursion  and  an  enfeebled  respiratory 
murmur  in  all  parts  of  each  lung.  Normal  resonance  is  elicited  upon 
percussion.  I  have  never  recognized  the  peculiar  character  of  the  respir- 
atory sounds  described  by  the  French  as  carnage,  which  is  ascribed  to  the 
rush  of  air  through  a  narrowed  lumen,  but  have  noted  an  inspiratory 
retraction  of  the  thorax,  the  so-called  tirage,  which  is  often  pronounced 
in  the  lower  lateral  region.  Edema  or  spasm  of  the  glottis  and  genuine 
diphtheria  may  be  excluded  by  laryngoscopic  examination  and  by  the 
fact  that  the  voice  is  unaffected  in  tracheal  obstruction. 

When  the  compression  is  exerted  upon  a  single  ■primary  bronchiis, 
there  is  but  moderate  dyspnea  unless  the  enlargement  of  the  gland  has 
taken  place  suddenly.  As  a  rule,  the  increase  in  the  size  of  the  affected 
glands  is  gradual  and  hence  the  pressure  occlusion  of  the  bronchus  is 
incomplete  and  the  dyspnea  slight.  In  such  cases  there  are  often  no 
symptoms  incident  to  the  pressure  upon  the  bronchus  per  se.  If  sub- 
jective clinical  manifostatioiis  are  present,  they  are  occasioned  by  pres- 
sure upon  otlier  cdiiti.iiuous  ]);uts.  as  will  he  explained. 

The  physical  signs  of  bronchial  compression,  however,  are  defined 
sharply  and  constitute  a  group  of  clinical  data  sufficient  to  characterize 
the  condition  and  lead  to  its  almost  invariable  recognition.  Upon 
inspection  the  restricted  moljility  of  the  affected  side  is  at  once  apparent. 
In  place  of  the  inspiratory  expansion  is  seen  a  more  or  less  pronounced 
retraction  in  the  lateral  region.  Upon  percussion  there  is  found  but 
slight,  if  any,  deviation  from  the  normal  resonance.  The  respiratory 
sounds  are  absent  altogether,  or  else  markeiUy  diminished  in  intensity, 
without  perceptible  difference  in  rhythm,  pitch,  or  quality,  save  for  the 
occasional  recognition  of  the  carnage.  In  exceptional  instances  a  capil- 
lary bronchitis  is  detected  by  the  presence  of  extremely  fine  moist  rales, 
which  are  disseminated  throughout  the  lung  of  the  affected  side.     This 


424  COMPLICATIONS 

condition  is  rarely  incident  to  the  compression  itself,  but  is  produced  by 
the  penetration  of  the  gland  en  masse  into  the  bronchus,  with  subsequent 
aspiration  of  tiny  particles  of  infective  material,  to  which  condition  atten- 
tion will  presently  be  directed.  The  presence  of  a  closed  pneumothorax 
may  be  excluded  by  the  failure  to  recognize  a  dislocation  of  the  cardiac 
apex,  together  with  other  signs  previously  alluded  to.  The  unchanged 
percussion  resonance  and  diminished  breath-sounds  then  permit  an 
assumption  as  to  the  existence  of  some  form  of  bronchial  obstruction. 
The  nature  of  the  obstruction  is  determined,  as  a  rule,  by  a  review  of 
such  essential  features  as  the  age,  history,  habits,  and  a  further  study 
of  the  physical  signs.  The  suspicion  of  a  foreign  body  in  the  bronchus 
may  usually  be  eliminated  by  the  history.  Aneurism  is  often  excluded 
by  the  age,  history,  and  associated  conditions,  together  with  the  absence 
of  signs  especially  characteristic  of  the  condition.  An  .r-ray  examina- 
tion is  sometimes  of  undoubted  value  in  obscure  cases. 

The  compression  of  other  contiguous  structures,  though  somewhat 
less  frequent  than  that  of  the  trachea  or  large  bronchi,  is  attended  by 
rather  more  conspicuous  symptoms. 

Pressure  upon  the  recurrent  laryngeal  nerve  may  produce  hoarseness 
or  aphonia,  together  with  a  paroxysmal  cough,  the  latter  often  being 
extremely  distressing.  (In  this  connection  it  is  interesting  to  note 
that  the  chronic  noisj^  breathing  of  hor.ses,  commonly  termed  "roaring," 
is  occasioned  by  pressure  upon  one  of  the  nerves  controlling  the  move- 
ments of  the  larynx  by  lymphatic  glands  within  the  chest.)  The 
cough  usually  persists  indefinitely  and  is  not  attended,  as  a  rule,  by 
an  inspiratory  whoop.  There  is  often  no  expectoration  whatever,  but 
if  present,  it  consists  almost  entirely  of  mucus.  The  laryngoscopic 
evidences  of  compression  of  the  recurrent  laryngeal  are  numerous  and 
varied.  There  may  be  paralysis  of  any  single  muscle,  and  in  some  cases 
of  a  pair  of  muscles,  as  all  the  movements  of  the  larynx  are  controlled  by 
the  recurrent  laryngeal  nerves.  Complete  or  partial  paralysis  of  at  least 
one  group  of  muscles  is  almost  always  observed.  Pressure  upon  the 
recurrent  laryngeal  may  produce  dyspnea,  irre.spectiveof  the  presence  or 
absence  of  bronchial  compression.  Dyspnea  is  also  effected  by  com- 
pression of  the  phrenic,  and  often  occurs  in  conjunction  with  hiccough. 
Painful  and  difficult  swallowing,  as  in  esophagismus,  sometimes  results 
from  esophageal  obstruction  or  compression.  Dr.  J.  N.  Hall  has  called 
attention  to  the  possible  development  of  the  traction  diverticula  in  the 
esophagus  from  contraction  changes  either  in  the  gland  or  in  the  esoph- 
ageal wall,  giving  rise  in  part  to  the  symptoms  of  obstruction.  He  also 
alludes  to  the  possible  effect  of  pressure  upon  the  pulmonary  arteiy  in  fa- 
cilitating the  tendency  to  pulmonaiy  tuberculosis  through  the  lessened 
blood-supply.  In  the  event  of  compression  of  the  superior  vena  cava  an 
impeded  venous  circulation  is  noted  in  the  veins  of  the  face,  arms,  and 
shoulders,  and  sometimes  over  the  anterior  surface  of  the  thorax.  In 
these  cases  the  network  of  distended  veins  is  plainly  discernible  upon  the 
skin.  Edema  of  the  lungs  may  result  from  compression  of  the  pulmo- 
nary veins.  Vomiting  or  tachycarcha  may  be  present  from  compression 
of  the  pneumogastric,  and  either  dilatation  or  contraction  of  the  pupil,  as 
a  result  of  pressure  or  irritation  of  the  sympathetic. 

It  should  be  borne  in  mind  that  the  pressure  symptoms  referable  to 
enlarged  bronchial  glands  are  occasioned  not  only  by  the  contiguiti/  of 
important  structures,  but  also  by  the  immobilitii  and  resistance  of  the 


TUBERCULOSIS    OF    THE    MEDIASTINAL    AND    MESENTERIC    GLANDS     425 

parts  in  contrast  with  the  easily  movable  and  yielding  walls  within  the 
abdominal  cavity. 

In  the  event  of  adhesion  to  immediate  structures,  with  perforation 
of  an  intervening  wall,  the  resulting  changes  are  often  of  especial 
importance.  The  gland  may  penetrate  the  bronchus,  soften,  and  permit 
the  aspiration  of  tiny  particles  of  infective  material  into  the  correspond- 
ing bronchial  tract.  The  symptoms  and  physical  signs  of  a  bronchiolitis 
are  not  infrequently  merged  into  an  acute  bronchopneumonia.  This 
form  of  pneumonia  of  tuberculous  origin  usually  induces  an  early  fatal 
termination.  Abscess  of  lung  and  pulmonary  gangrene  may  possibly 
develop  as  secondary  processes  following  the  perforation  of  a  bronchus. 

Many  instances  are  on  record  relative  to  the  discovery  at  autopsy 
of  bronchial  glands  in  the  air-passages.  In  many  of  these  cases  the 
gland  producing  the  obstruction  was  found  to  be  of  such  size  as  to  pre- 
vent its  expulsion  through  the  trachea  and  larynx.  It  is  not  altogether 
impossible  that  a  sloughing  gland  may  be  expectorated.  Some  years 
ago  Hall  reported  a  case  of  obstruction  of  the  left  primary  bronchus, 
which  was  presumably  from  a  tuberculous  gland.  This  was  followed  by 
bronchopneumonia  of  the  adjacent  lung,  with  expectoration  of  a  large 
amount  of  pus  daily,  without  evidence  of  empyema  or  bronchiectasis. 
There  was  an  abrupt  cessation  of  the  expectoration,  with  speed}-  com- 
plete recovery  after  the  expectoration  of  a  "  fleshy  mass,  presumably  a 
bronchial  gland."  Dr.  Hall  was  unable  to  secure  the  supposed  glandular 
obstruction  for  the  purpose  of  examination. 

Cases  of  calcareous  metamorphosis  of  the  affected  gland  have  been 
reported,  with  the  expectoration  of  so-called  lung  stones. 

When  perforation  takes  place  into  the  trachea,  sudden  and  alarming 
dyspnea  invariably  supervenes.  Such  a  condition  is  the  probable 
cause  in  many  in-stances  of  sudden  death  in  little  children  following 
abrupt  and  severe  dyspnea.  Several  cases  confirmed  by  autopsy  have 
been  reported.  Instances  of  perforation  of  the  esophagus  by  an  ulcer- 
ating gland  are  fairly  numerous,  as  well  as  rupture  into  the  pleura  and 
pericardium. 

Although  glandular  perforation  is  by  no  means  essential  for  the  pro- 
duction of  tuberculous  pleiuisy  and  pericarditis,  these  secondary  proc- 
esses, together  with  pneumothorax  and  mediastinal  abscess,  are  some- 
times the  chrect  result  of  a  suppurating  tuberculous  gland.  Perfor- 
ation of  the  wall  of  the  larger  blood-vessels  is  comparatively  infre- 
quent, but  has  been  found  to  take  place  in  the  pulmonarj'  artery 
and  the  aorta.  Ulceration  into  a  vein  establishes  a  direct  communi- 
cation of  the  softening  gland  with  the  blood-current,  and  results  in  a 
miliary  tuberculous  infection. 

Tuberculous  meningitis,  as  well  as  the  other  forms  of  general  miliary 
tuberculosis,  are  known  to  be  secondary  in  a  large  proportion  of  cases  to 
involvement  of  the  bronchial  glands,  both  the  blood-  and  lymph-currents 
constituting  the  avenue  of  infection  from  tlie  primary  focus.  In  view 
of  the  remarkable  frequency  of  tulierculous  involvement  of  the  tracheo- 
bronchial glands  it  is  difficult  to  explain  the  comparative  rarity  of  general 
tuberculous  infection.  It  is  certain,  however,  that,  through  the  medium 
of  the  lymphatics,  extension  of  the  tuberculous  process  takes  place  in 
neighboring  organs,  notably  the  lung. 

It  is  important  to  bear  in  mind  that  in  children  pulmonary  tuber- 
culosis emanating  from  a  diseased  bronchial  gland  presents  a  somewhat 


426  COMPLICATIONS 

different  clinical  picture  than  in  adults  as  regards  the  localization  of  the 
area  of  infection.  In  children  the  apex  is  usually  uninvolved  at  first, 
the  infection  spreading  from  the  hilus  in  the  immediate  neighborhood  of 
the  primary  glandidar  focus  to  the  middle  and  lower  portions  of  the 
lung.  Involvement  of  the  lower  lobe  is  often  produced  by  the  aspir- 
ation of  cheesy  portions  of  gland  penetrating  a  larger  bronchus.  In  the 
absence  of  an  ulcerating  gland  within  the  bronchus,  permitting  a  down- 
ward extension  of  the  tuberculous  process,  the  area  of  initial  pulmonary 
infection  is  closely  adjacent  to  the  bronchial  glands,  between  the  second 
and  fifth  dorsal  vertebrsp.  An  investigation  of  the  middle  or  lower 
portion  of  the  back  in  children  is  usually  attended  by  positive  results. 
In  this  region  signs  of  beginning  consolitlation  with  bronchial  or  bron- 
chovesicular  respiration  and  fine  or  medium-sized  moist  rales  are  recog- 
nized. 

Enlarged  tracheobronchial  glands  often  give  rise  to  no  physical  evi- 
dences at  the  immediate  site  of  their  location,  but  if  pressure  sijmptoms 
are  exhibited,  an  early  and  con\-incing  diagnosis  can  be  matle  in  many- 
instances.  In  other  words,  the  physical  signs  referable  to  the  compres- 
sion of  a  bronchial  gland  are  sufficient  in  character  in  connection  with 
associated  data,  to  justify  a  definite  diagnosis  as  to  the  nature  of  the 
obstruction.  The  clinical  detection,  however,  of  the  enlarged  glands 
themselves  is  often  impossible,  even  if  of  sufficient  size  to  produce  pres- 
sure symptoms.  It  is  true  that  in  some  cases  a  considerable  enlarge- 
ment of  the  bronchial  glands  is  possible  of  recognition,  although  the  mass 
may  be  so  situated  as  to  exert  no  pronounced  compression  upon  import- 
ant structures. 

It  is  claimed  by  some  observers  that  dulness  upon  percussion  ma}'  be 
recognized  in  the  interscapular  space  in  the  neighborhood  of  the  fifth 
dorsal  vertebra,  and  especially  just  aliove  this  area.  I  have  never 
been  able  to  detect  changes  in  resonance  in  this  region  in  cases  of 
suspected  glandular  enlargement.  Many  authors  deny  the  existence 
of  such  percussion  change  unless  the  glands  are  of  extreme  size.  In  a 
very  few  instances  I  have  been  able  to  recognize  percussion  dulness 
referable  to  glandular  enlargement  just  below  the  sternocla\icular 
articulation  upon  one  side.  The  percussion  change  is  rendered  more 
pronounced  if  the  head  is  held  well  retracted  during  a  deep  inspiration. 
Recognition  is  ea.sier  in  young  adults  than  in  little  children  on  account 
of  the  tliminished  size  of  the  thymus  gland. 

But  little  dependence  can  be  placed  upon  any  circumscribed  auscul- 
tatory signs  supposedly  attributable  to  glandular  enlargement.  There 
may  be,  in  some  cases,  enfeebled  respiratory  sounds  and  in  others  a 
distinct  bronchovesicular  element  due  to  conduction  through  a  solid 
gland.  At  best  both  the  percussion  and  auscultatory  signs  over  the 
site  of  the  tuberculous  gland  are  vague  and  indefinite,  save  in  instances 
of  very  pronounced  enlargement.  To  illustrate  certain  points  to  which 
attention  has  been  directed.  I  will  report  briefly  the  case  of  a  young 
man  which  is  of  exceeding  interest  in  this  connection. 

The  patient,  aged  twenty-eight  .vears,  was  sent  to  Colorado  during 
the  latter  part  of  1905  on  account  of  advanced  pulmonary  tuberculosis, 
the  symptoms  of  which  immediately  followed  an  attack  of  croupous 
pneumonia.  At  that  time  there  were  severe  paroxysmal  cough, 
copious  expectoration,  rigors,  fever,  night-sweats,  and  dyspnea.  The 
patient  was  referred  to  me  in  March,  1907,  by  a  prominent  physician  in 


TUBERCULOSIS    OF    THE    MEDIASTINAL    AND    MESENTERIC    GLANDS     427 

another  part  of  the  State,  under  whose  direction  he  had  remained  while 
in  Colorado.  The  average  afternoon  temperature  was  103°  F.  and 
occasionally  higher.  Dyspnea  was  pronounced,  cough  severe  and 
markedly  paroxysmal,  the  expectoration  amounting  to  six  ounces  in 
twenty-four  hours.  Upon  examination  of  the  chest  there  was  noted 
a  slightly  impaired  mobility  of  the  entire  left  side,  with  inspiratory 
retraction  in  the  lateral  region.  The  percussion  resonance  was  normal, 
and  there  was  no  cardiac  displacement.  There  was  recognized  a 
considerable  diminution  in  the  intensity  of  the  respiratory  sounds, 
with  very  fine  moist  rales  over  the  entire  left  lung.  Slight  moisture 
was  present  at  the  right  apex,  without  evidence  of  infiltration.  Occlu- 
sion of  the  left  primary  bronchus  from  a  tuberculous  mediastinal 
gland  was  suggested,  and  an  effort  made  to  detect  localized  percussion 
changes.  Percussion  of  the  liack  from  the  third  to  the  fifth  dorsal  spine 
was  entirely  negative.     No  deviation  from  normal  resonance  was  elicited 


in  the  left  sternoclavicular  articulation  with  the  head  held  perfectly 
erect.  When  it  was  thrown  well  back,  however,  and  particularly  upon 
deep  inspiration,  there  was  noted  upon  light  percussion  a  slight  but 
distinct  dulness,  the  outline  of  which  is  shown  in  the  accompanying 
photograph  (Fig.  113).  There  was  thus  established  a  positive  diagnosis 
of  obstruction  to  the  left  primary  bronchus  near  the  bifurcation  of  the 
trachea  by  a  tuberculous  bronchial  gland.  This  was  confirmed  the 
following  day  by  the  .r-ray  picture  (Fig.  55),  the  enlarged  gland  being 
found  in  close  apposition  to  the  .sixth  dorsal  vertebra  upon  the  left  side. 
There  was  no  hoarseness  or  aphonia,  but  the  laryngoscopic  image  clearly 
showed  a  partial  paralysis  of  the  abductors,  indicating  that  the  mass  was 
impinging  to  at  least  a  slight  extent  upon  the  nerve  controlling  the  move- 
ments of  the  larynx. 

Dr.  Levy's  report  of  the  laryngoscopic  examination  follows:  "No 
apparent  change  in  the  mobility  of  the  vocal  bands  upon  tranquil  respir- 
ation.    Upon  forced  inspiration  abductor  excursion  of  the  left  vocal 


428  COMPLICATIONS 

band,  limited  to  an  extent  equal  to  about  one-half  that  of  the  right;  upon 
phonation  a  small  chink  l)et\vcen  the  vocal  bands,  due  to  paresis  of  the 
internal  thyro-arytenuid  muscle;  line  of  approximation  was  obliquely 
to  the  right,  owing  to  exaggeration  of  the  action  of  the  adductor  of  the 
left  vocal  band  over  the  abductor,  causing  an  overriding  of  the  left  aryte- 
noid in  front  of  the  right. 

"Diagnosis. — Slight  pressure  upon  the  left  recurrent  laryngeal  or 
left  pneumogastric,  involving  only  the  abductor  fibers,  and  these  but 
slightly. 

"  The  fibers  of  the  recurrent  laryngeal  going  to  the  abductors  of  the 
larynx  are  first  affected  in  pressure  lesions  of  this  nerve  or  of  the  pneumo- 
gastric, in  accordance  with  the  law  laid  down  by  Semon,  which  is  to  the 
effect  that  when  pressure  is  made  upon  the  recurrent  laryngeal,  the  fibers 
going  to  the  abductors  are  first  involved,  owing  to  a  peculiar  suscepti- 
bility of  these  fibers.  The  first  manifestation  of  pressure  upon  the 
recurrent  laryngeal,  therefore,  is  abductor  paralysis.  As  the  pressure 
continues  the  adductors  become  paralyzed  as  well,  thus  giving  to  the 
vocal  band  neither  abduction  nor  adduction,  allowing  it  to  remain  in 
what  is  known  as  the  cadaveric  position." 

The  subsequent  progress  of  the  case  under  the  use  of  tuberculin  and 
an  autogenetic  vaccine  is  detailed  under  Specific  Mechcation. 

MESENTERIC  GLANDS 

Tuberculosis  of  the  mesenteric  and  retroperitoneal  glands,  commonly 
termed  tabes  mesenterica,  is  frequently  foimd  at  autopsy  to  have  been 
present  in  little  children,  even  though  unsuspected  during  life.  Suppu- 
ration takes  place  far  less  often  than  in  the  glands  of  the  cervical  region. 
Caseation  is  common,  and  calcification  sometimes  occurs.  The  condition 
is  found  with  great  frequency  among  the  neglected  children  of  the  very 
poor.  The  patient  is  usually  quite  anemic  and  poorly  nourished.  The 
trunk,  arms,  and  legs  are  thin  and  wasted,  while  the  belly  is  quite  prom- 
inent. The  abdominal  enlargement  is  produced  more  from  the  coexist- 
ing tympanites  than  from  the  direct  presence  of  the  glamls  themselves. 
Diarrhea  is  often  present,  and  the  stools  are  offensive,  and,  as  a  rule,  the 
appetite  and  digestion  are  considerably  impaired.  The  older  writers 
however,  speak  of  "  emaciation  and  voracity  combined' '  in  such  cases. 
There  are  almost  always  fever,  peevishness,  and  irritability. 

As  a  rule,  little  is  determined  upon  examination  on  account  of  the 
tympanitic  condition  of  the  bowels.  The  glands  are  rarely  felt.  In  case 
of  coexisting  tuberculous  peritonitis  the  abdomen  may  be  firm,  resistant, 
and  presenting  nodular  enlargements.  In  some  in.stances  tuberculous 
involvement  of  glands  is  recognized  in  other  regions,  notably  the  cervical 
and  axillary. 

This  type  of  glandular  tuberculosis  often  is  observed  among  negroes, 
and  is  not  infrequent  in  adults  among  these  people. 


TREATMENT    OF    GLANDULAR    TUBERCULOSIS  429 


CHAPTER   LXII 
TREATMENT  OF  GLANDULAR  TUBERCULOSIS 

While  in  the  past  tuberculosis  of  the  cervical  lymph-nodes  has  been 
subjected  to  a  variety  of  local  remedial  efforts,  both  non-operative  and 
surgical,  involvement  of  the  mediastinal,  mesenteric,  and  retroperitoneal 
glands  has  not  been  regarded  as  amenable  to  other  than  constitutional 
treatment.  The  general  management  of  all  cases  of  glandular  tuber- 
culosis has  consisted  chiefly  of  tonic  and  supporting  measures,  which  in 
cervical  adenitis  have  been  supplemented  by  local  procedures.  The 
present  conception  of  the  proper  treatment  of  glandular  tuberculosis 
affords  a  reasonable  belief  in  the  attainment  of  more  satisfying  results 
than  formerly.  It  is  now  appreciated  that  a  tuberculous  gland,  no 
matter  how  small,  may  be  an  active  focus  for  further  tuberculous  infec- 
tion, and  hence  the  necessitij  of  instituting  without  delay  an  intelligent 
systematic  course  of  treatment  even  to  incipient  cases. 

While  the  lymphatic  glands  of  the  neck  comprise  a  group  especially 
suited  for  surgical  interference,  the  glands  of  the  mediastinum  and 
abdomen,  after  the  diagnosis  has  become  definitely  established,  some- 
times respond  to  active  therapeutic  efforts  in  conformity  with  compara- 
tively new  ideas  of  management.  The  modern  treatment  of  glandular 
tuberculosis  may  be  regarded  as  general  and  local . 

GENERAL  TREATMENT 

This  form  of  management  embraces  the  hygienic  treatment  and  the 
medicinal. 

Hygienic  Treatment. — The  hygienic  principles  of  treatment  relate 
especially  to  an  abundance  of  outdoor  air,  exercise,  chversion,  change  of 
environment,  and  nutritious  food.  In  glandular  infections,  as  in  all 
other  forms  of  surgical  tuberculosis,  attention  to  no  single  factor  is  suf- 
ficient for  the  accomplishment  of  the  best  results.  An  out-of-door 
existence,  important  though  it  be,  is  totally  inadequate  by  itself,  but 
should  be  combined  with  such  favorable  influences  as  accrue  from 
judicious  exercise,  with  opportunities  for  recreation  and  amusement. 
There  should  also  be  an  ingestion  of  food  sufficient  in  character  and 
quantity  to  appease  the  cravings  of  ;ui  iHiic;i.siiif;  .-ii  (petite.  It  is  difficult 
to  conceive  of  the  inestimable  benefits  (Icincd  by  liltic  children  from  a 
radical  change  in  their  immediate  sunoundiugs.  Kemoval  from  the 
city  to  the  country  or  the  seashore  not  only  permits  a  greater  purity 
of  the  air,  but  affords  a  natural  incentive  for  more  or  less  unwonted 
exercise,  and  provides  a  means  for  the  enjoyment  of  unaccustomed 
sights,  which  awaken  the  interest  and  maintain  a  buoyancy  of  spirits  in 
the  young.  The  p.sychic  influence  of  a  novel  environment  even  among 
the  well-to-do  is  of  undoubted  value,  while  such  a  change  is  a  veritable 
blessing  to  the  poor,  who,  since  their  birth,  have  been  deprived  of  sun- 
light, fresh  air,  proper  food,  and  clothing,  cheerful  surroundings,  and 
uplifting  influences. 

In  a  vast  number  of  cases  of  glandular  tuberculosis  the  actual  needs 
of  the  child  are  better  subserved  by  attention  to  these  hygienic  features 
of  treatment  than  through  recourse  to  purely  medicinal  or  surgical 
management. 


430  COMPLICATIONS 

By  an  outdoor  regime  is  meant  far  more  than  the  air  permitted  to 
enter  sleeping-rooms  and  hospital  wards  through  open  windows.  It  is 
not  always  an  eas}-  matter  to  persuade  parents  that  their  duty  to  the 
child  consists  of  provision  for  a  recreative  existence  in  the  open  air  as 
the  first  essential  of  treatment.  The  inconvenience  of  the  family,  the 
additional  expenditure,  and  the  social  or  business  interruptions  are 
assuredly  unworthy  of  consideration  in  comparison  with  the  boon 
granted  by  virtue  of  a  radically  changed  environment. 

Clinical  evidence  is  now  conclusive  to  the  effect  that  many  cases  of 
glandular  tuberculosis  are  clearly  susceptible  of  rapid  and  permanent 
cure,  through  the  adoption  of  an  unrestricted  out-of-door  existence. 
While  this  principle  of  open-air  treatment,  exclusive  of  surgical  manage- 
ment, is  thoroughly  recognized,  a  considerable  chfference  of  opinion  is 
entertained  with  reference  to  the  comparative  merits  of  the  sea,  inland, 
or  mountain  air.  The  French  and  English  appear  to  have  an  abiding 
faith  in  the  efficacy  of  sea  air  for  children  afflicted  with  tuberculous 
glands  or  bones.  In  the  latter  part  of  the  eighteenth  centurv  the  Royal 
Sea  Bathing  Hospital  was  founded  at  Margate,  England.  Since  then 
convalescent  homes  for  invalids  suffering  from  so-called  surgical  tuber- 
culosis have  been  established  upon  the  seashore  of  England.  At  the 
present  time  nearly  all  European  cotmtries  maintain  hospitals  upon  the 
coast  for  invalids  similarly  afflicted. 

Brannan,  the  prime  mover  in  organizing  the  work  of  our  single  experi- 
mental station  at  Sea  Breeze,  which  is  supported  by  the  New  York 
Association  for  Improving  the  Condition  of  the  Poor,  reports  23  marine 
hospitals  along  the  Italian  .shores  of  the  Mediterranean  and  Adriatic, 
containing  a  total  of  over  10.000  beds. 

Calot  has  described  the  hospital  at  Berck-sur-mer,  which  was  founded 
by  the  city  of  Paris  in  1860  and  now  contains  750  beds. 

In  this  institution  remarkable  improvement  has  been  achieved  by 
one  of  my  former  patients,  who  became  afflicted  with  Pott's  disease. 
While  the  child  was  still  an  infant  the  father,  a  physician  of  New  York 
city,  died  in  Colorado,  in  1898,  as  the  result  of  a  severe  pulmonary 
hemorrhage  occurring  in  the  course  of  advanced  phthisis.  A  few 
years  later  the  child  was  sent  to  Berck-sur-mer,  where  he  remained 
for  a  period  of  nearly  two  years  and  secured  an  apparent  complete 
recovery  from  the  tuberculous  process.  The  child  was  taken  daily  from 
the  bed  and  placed  upon  a  truck,  which  was  rolled  almost  to  the  water's 
edge.  There  he  was  permitted  to  lie  during  the  entire  da}%  save  imder 
unusually  se\-ere  weather  conditions.  This  is  practised  as  a  routine 
measure  at  the  several  institutions  at  Berck-sur-mer. 

There  are  several  seashore  hospitals  in  South  America  containing  over 
800  beds,  largely  devoted  to  the  treatment  of  tuberculosis  of  cliilclhood. 
It  appears  that  nearly  all  the  countries  of  Europe  and  some  in  South 
America  have  been  far  more  ready  than  the  United  States  to  make 
national  provision  for  the  care  of  little  sufferers  with  various  forms  of 
surgical  tuberculosis. 

Brannan  calls  attention  to  the  fact  that  France  maintains  on  her 
sea-coast  fifteen  sanatoria,  which,  with  other  institutions,  open  only 
during  a  portion  of  the  year,  contain  4000  beds.  He  quotes  the  reports 
presented  by  Armaingand  and  D'Espine  at  the  International  Congress 
of  Tuberculosis  in  Paris  in  Octolier,  190.5.  concerning  the  work  done  in 
the  various  seaside  sanatoria  of  Europe.     During  the  past  twenty  years 


TREATMENT  OF  GLANDULAR  TUBERCULOSIS  431 

60,000  children  have  been  treated  in  these  sanatoria  in  France,  84  per 
cent,  of  whom  exhibited  favorable  results;  of  these,  59  per  cent,  were 
regarded  as  absolute  cures,  and  25  per  cent,  as  instances  of  pronounced 
improvement.  Of  those  absolutely  cured,  the  percentage  ranged  from 
32  in  Pott's  disease,  to  74  in  glandular  tuberculosis.  Nearly  all 
European  seaside  institutions  exclude  pulmonary  tuberculosis. 

The  consensus  of  opinion  abroad  is  strongly  in  favor  of  the  seaside 
resorts  as  opposed  to  inland  climates  for  the  treatment  of  tubercu- 
losis of  childhood.  The  results  already  accomplished  at  Sea  Breeze 
are  instructive  and  inspiring.  There  has  been  an  almost  invariable 
improvement  in  the  general  conilition  of  the  children,  with  a  corres- 
ponding change  in  the  local  le.sions.  These  results  have  been  attained 
by  virtue  of  the  new  surroundings  in  connection  with  non-operative 
therapeutic  measures.  Out  of  a  total  of  ten  cases  of  glandular  tuber- 
culosis, six  have  been  entirely  cured  and  three  very  much  improved. 
The  essentials  of  ti-eatment  at  Sea  Breeze  are  constant  exposure  to  the 
sea  air  by  night  as  well  as  day,  abundant  nourishment,  and  the  establish- 
ment of  a  bright,  happy  child-life  for  the  little  patients.  They  are 
allowed  to  exercise  to  a  remarkable  extent,  playing  and  romping  in  the 
sand  in  spite  of  their  physical  infirmities. 

Halsted,  in  his  paper  before  the  Clinical  and  Climatological  Section 
at  the  first  meeting  of  the  National  Association  foi-  the  Study  and  Pre- 
vention of  Tuberculosis,  reports  decidedl.y  iiratif\iiiK  results  obtained  l)y 
inland  out-of-door  management.  His  early  iilisciNatimis  concfrning  the 
efficacy  of  the  open-air  treatment  were  conlined  to  the  "  bridge' '  of  the 
Johns  Hopkins  Hospital. 

Unusual  results  in  surgical  tuberculosis  have  been  obtained  in  the 
Adirondacks  and  other  eastern  inland  resorts.  Lowman  believes  that 
along  the  borders  of  the  Great  Lakes  there  may  be  accomplished  results 
in  all  respects  equal  to  those  obtained  at  the  seashore.  Morse  has  called 
attention  to  the  Convalescent  Home  at  Wellesley,  established  many 
years  before  Sea  Breeze,  and  employing  practically  the  same  methods. 
He  asserts  from  the  experience  at  Wellesley  that  the  sea  air  is  by  no 
means  a  sine,  qua  non,  and  that  children  may  be  expected  to  do  fully  as 
well  in  the  country  as  at  the  seashore. 

Freeman  affirms,  from  a  surgical  experience  of  over  seven  years  in 
Colorado,  and  of  equal  duration  in  Cincinnati,  that  moderately  high 
altitudes  with  dryness  offer  far  gi'eater  advantages  than  the  seashore 
for  the  treatment  of  glandular  and  bone  tuberculosis.  He  reports 
remarkably  fewer  cases  of  tuberculosis  of  the  lymphatic  glands  in  Colo- 
rado than  in  Ohio.  Powers,  after  ten  years'  resiclcnco  in  Colorado,  fol- 
lowing an  equal  period  in  New  York,  arrives  at  the  same  coni'lusion. 

From  an  experience  of  sixteen  years  in  this  Stuti-  1  feel  warranted 
in  asserting  that  both  tubei'culosis  of  the  uhmds  .■uid  bones  is  decidedly 
infrequent,  the  vast  ma,joi-it\-  of  siidi  |iHtieiils  <'oiiiiii,ij,  from  a  distance  to 
avail  themselves  of  climatic  advantages.  It  is  highly  significant  that 
amidst  a  large  invalid  population  with  innumerable  children  born  of 
tuberculous  parents,  exceedingly  few  incUgenous  cases  of  glandular  tuber- 
culosis are  observed.  Even  among  a  moderately  large  negro  population, 
who  in  other  regions  exhibit  not  uncommonly  tuberculosis  of  all  the 
glands  of  the  body,  there  are  observed  in  this  State  but  comparatively 
few  instances  even  of  localized  glandular  infection.  It  is  reasonable  to 
believe  that  a  rarefied,  stimulating  atmosphere,  with  many  hours  of 


432  COMPLICATIONS 

sunshine,  should  be  more  beneficial  for  individuals  with  diminished 
resistance  than  a  climate  teeming  with  fog,  frequently  saturated  with 
moisture,  thus  permitting  less  opportunity  for  out-of-door  recreation. 

Wai^dng  at  this  time  any  extended  consideration  of  the  value  of 
climate  in  the  treatment  of  glandular  tuberculosis,  great  emphasis 
should  be  added  to  hygienic  management  in  the  open  air,  with  ample 
exercise,  as  an  indispensable  therapeutic  factor,  whether  at  the  seashore, 
in  the  country,  at  the  lakeside,  or  in  the  mountains. 

While  the  doctrine  of  conservative  open-air  treatment  for  cases  of 
glandular  and  bone  tuberculosis  in  children  is  accorded  a  general  accept- 
ance in  modern  text-books  upon  surgery,  it  would  seem  that  the  present 
teaching  as  to  the  efficacy  of  fresh  air,  sunlight,  and  exercise  is  consider- 
;ilil\-  ill  advance  of  the  actual  niethods  coinmonhj  practised  by  physicians 
ami  -umiMins  in  assuming  to  chrect  the  destinies  of  these  patients.  It  is 
HI  It  >\ilii(  lent  to  advise  in  a  perfunctory  way  that  the  child  should  be  kept 
out-of-doors.  The  obligation  of  the  attending  practitioner  is  not  dis- 
charged until  he  has  urged,  in  an  active  personal  capacity,  the  necessity 
of  change  to  the  country,  the  seashore,  or  the  mountains,  as  may  appear 
most  practicable  in  indi%'idual  cases.  Further,  the  so-called  ambulatory 
treatment  in  the  open  air  is  not  alone  applicable  to  cases  convalescing 
from  operation,  but  in  many  instances  is  equally  appropriate  for  con- 
ditions formerly  supposed  to  demand  immediate  operative  interference. 

The  vital  consideration,  irrespective  of  age,  is  the  greater  resistance 
to  tuberculosis  accruing  from  an  outdoor  existence  in  favorable  climates, 
\\ith  suitable  provision  for  cUversion,  recreation,  and  exercise. 

Apropos  of  the  present  conception  concerning  the  vast  importance 
of  the  purely  hygienic  principles  of  management,  it  is  of  considerable 
historic  interest  to  re^^ew  the  practice  in  vogue  in  the  early  centuries, 
based  upon  an  abiding  faith  in  the  efficacy  of  the  kingly  touch  in  the 
cure  of  scrofula.  The  antiquity  of  the  belief  has  been  established, 
together  with  a  mass  of  almost  credible  evidence  as  to  its  value. 

In  France  the  practice  dates  back  to  the  time  of  Clovis  in  481  A.  D. 
In  England  this  method  of  treatment  was  introduced  by  Edward  the 
Confessor,  who  reigned  from  1044  to  1066.  The  disease  was  commonly 
regarded  as  "a  vice  in  the  .sj-stem,"  and  possible  of  eradication  only 
through  the  purification  afforded  by  the  royal  touch.  Scrofula,  there- 
fore, was  popularl}'  called  "the  king's  evil."  During  a  period  of  seven 
hundred  years  this  custom  was  followed  by  the  reigning  monarchs  of 
England  and  consisted  of  the  laying  on  of  hands.  Henry  the  Seventh 
originated  the  plan  of  tj'ing  a  ribbon  around  the  neck,  to  which  was 
attached  either  a  silver  or  a  gold  coin.  Historians  cUffer  as  to  the  per- 
formance of  the  practice  by  Mary,  William,  and  Ann.  It  was  believed 
by  many  people  that  these  rulers  did  not  possess  the  hei'ecUtary  gift 
of  healing,  for  the  ascribed  reason  that  they  did  not  occupy  the  throne 
by  Divine  right.  Writers  of  history  assert  that  multitudes  came  from 
great  lUstances  to  avail  themselves  of  the  wondrous  benefits  to  be 
acquired  through  the  sovereign  touch.  Charles  the  Second  is  reputed 
to  have  treated  in  the  neighborhood  of  100,000  people  suffering  from 
the  king's  e\il  during  a  period  of  twelve  years.  Louis  XIV.  of  France, 
upon  Easter  Sunday.  1686,  is  reported  to  have  treated  over  1600  people. 
That  a  not  altogether  implicit  faith  in  the  efficacy  of  the  method  was 
entertained  by  the  French  ruler  is  suggested  by  the  words,  "The  king 
has  touched  j'ou,  ma}'  God  cure  you." 


TREATMENT    OF    GLANDULAR    TUBERCULOSIS  433 

John  Browne,  Chirurgeon  in  Ordinary  to  his  Majesty  of  England  in 
1684,  has  written  several  treatises  concerning  "the  real  art  of  healing 
strumae  by  the  imposition  of  the  sacred  hands  of  our  kings  of  England 
and  France  given  them  at  their  inaugurations."  Dr.  H.  F.  Stoll  has 
recently  called  attention  to  the  interesting  fact  that  although  Browne 
lived  in  an  age  of  superstition  and  frequently  assisted  the  king  in  the 
ceremony  of  royal  touch,  he,  nevertheless,  stated  in  his  writings  that  the 
malady  was  "no  fictitious  distemper  or  imaginary  e\Tl,  but  rather  a 
proper  disease." 

In  the  light  of  our  present  knowledge  regarding  the  probable  elas- 
ticity of  the  term  "  scrofula' '  as  then  applied,  and  also  concerning  the 
beneficial  effect  of  travel,  life  in  the  open  air,  and  buoyancy  of  spirits, 
it  is  not  unlikely,  as  Halsted  suggests,  that  the  prolonged  pilgrimages 
from  remote  points,  the  protracted  journeyings  in  the  open  air,  the 
invigoration  incident  to  changed  surrounding.s  and  renewed  hope,  served 
effectually  to  delude  the  sufferers  as  to  the  efficacy  of  this  supernatural 
method  of  healing. 

Medicinal  Treatment. — For  many  years  the  purely  medicinal  treat- 
ment of  glandular  tuberculosis  has  related  largely  to  the  administration 
of  iodid  of  iron  and  cod-liver  oil.  With  no  desire  to  detract  from  the 
undoubted  value  of  these  remedies,  in  a  large  majority  of  cases  it  is,  never- 
theless, true  that  the  benefits  to  be  derived  from  their  use  are  decidedly 
inferior  to  the  results  afforded  by  general  hygienic  management.  Medi- 
cinal agents  of  any  kind  are  not  indicated  invariably  in  these  cases, 
and  when  employed  at  all,  should  not  be  prescribed  in  accordance  with 
a  conventional  or  routine  method.  Attention  to  digestion  is  of  the 
utmost  importance.  The  correction  of  such  disturbances  through  diet- 
ary precautions  and  medicinal  aids  is  of  much  more  value  than  the 
administration  of  cod-liver  oil,  arsenic,  or  the  ferruginous  tonics. 

The  appetite  is  usually  capricious  at  best,  and  the  digestive  function 
more  or  less  enfeebled.  In  such  cases  the  indications  point  more  to 
the  consumption  of  greater  quantities  of  nutritious  food  than  to 
enforced  dosage  with  drugs.  In  the  absence  of  distinct  contraindica- 
tions, however,  it  is  excellent  practice  to  use  the  syrup  of  the  iodid  of 
iron,  alternating  occasionally  with  Fowler's  solution,  given  well  toward 
the  limit  of  toleration.  The  various  preparations  of  iron,  manganese, 
cod-liver  oil,  or  easily  cUgestible  fats  are  often  of  undoubted  value,  pro- 
vided that  appetite  and  digestion  are  not  impaired.  Aids  to  nutrition 
in  this,  as  in  other  forms  of  tuberculosis,  may  be  expected  to  increase 
vital  resistance. 

Specific  medication  of  unquestionable  merit,  applicable  to  all  forms 
of  glandular  and  bone  tuberculosis,  has  recently  been  employed.  The 
administration  of  the  bacilli  emulsion  of  Koch  to  cases  of  glandular 
tuberculosis  opens  an  entirely  new  therapeutic  field  and  is,  perhaps, 
destined  to  yield  gratifying  results  in  many  cases  thus  far  but  little 
amenable  to  management.  Wright's  work  adds  confirmation  to  the 
value  of  this  agent  as  applied  to  nearly  all  cases  of  surgical  tubercu- 
losis. Although  his  reported  results  suggest  the  predominant  value  of 
the  new  tuberculin'  in  cases  preisenting  a  localized  focus  of  tuberculous 
infection,  as  in  tuberculous  bones  and  joints,  highly  satisfactory  results 
are  sometimes  obtained  in  carefully  selected  cases  of  pulmonary  tuber- 
culofsis. 

With  the  addition  of  the  bacilli  emulsion  to  the  armamentarium 


434  COMPLICATIONS 

of  the  physician,  the  future  of  children  afflicted  with  enlargement  of 
mediastinal  and  mesenteric  glands  is  rendered  somewhat  brighter. 
After  a  provisional  establishment  of  the  diagnosis  by  the  sidjjective  and 
objective  signs,  together  with  the  use  of  the  x-ray,  ample  justification  is 
afforded  for  the  cautious  administration  of  the  tuberculin. 

LOCAL  MEASURES 

Local  efforts,  limited  to  the  cervical  glands,  relate  to — (1)  Non- 
operative  measures,  embracing  counterirritation,  massage,  electrolysis, 
the  J"-ray,  and  (2)  surgical  procedures,  including  aspiration,  interstitial 
injections,  incision,  and  drainage,  with  or  without  curetment  or  cauteriz- 
ation, and,  finally,  complete  excision. 

Local  non-operative  measures  should  consist  primarily  of  efforts 
to  remove,  as  far  as  possible,  all  sources  of  infection.  It  is  of  essential 
importance  to  investigate  the  condition  of  the  tonsils,  pharynx,  teeth, 
nose,  ears,  and  scalp.  Hypertrophied  tonsils  containing  deep  crypts 
should  be  removed  immediately.  Excellent  results  are  sometimes 
obtained  by  painting  the  tonsils  and  posterior  pharynx  with  solutions 
of  iodin  containing  potassium  iodid.  There  is  no  doubt  that  l)enefit  is 
obtained  by  the  use  of  chsinfecting,  stimulating,  and  astiiugent  applica- 
tions to  these  parts.  Attention  should  be  given  to  catarrhal  comlitions 
of  the  nose  and  inflammations  of  the  ears  and  scalp.  Stark  and  Koerner, 
according  to  Dr.  Leonard  Freeman,  found  decayed  teeth  in  41  per  cent, 
and  73.8  per  cent,  respectively  in  their  cases  of  glandular  tuberculosis. 

Counterirritation  by  ointments  or  stimulating  solutions  containing 
preparations  of  iodin,  ichthyol,  and  resorcinol  is  still  extensively  em- 
ployed, although  its  utility  is  extremely  doubtful  and  quite  unsus- 
tained  by  practical  results.  The  use  of  these  external  applications 
must  be  regarded  rather  in  the  nature  of  a  placebo,  but  the  necessity  for 
such  practice  seldom  exists.  In  addition  to  the  negative  effect  there  is 
usually  entailed  a  loss  of  valuable  time  before  the  institution  of  rational 
measures,  during  which  period  the  patient  is  exposed  to  the  constant 
danger  of  further  infection. 

Massage  of  the  glands  is  unworthy  of  other  than  condemnatory  men- 
tion. The  practice  of  manipulating  the  structures  is  distinctly  danger- 
ous upon  the  score  of  increasing  the  possibility  of  further  dissemination. 

Electrolysis  has  been  found  uniformly  ineffective,  its  employment 
being  based  upon  the  densest  ignorance,  or  constituting  a  form  of 
unjustifiable  deception. 

The  x-ray  is  of  undoubted  efficacy  in  the  treatment  of  many  cases  of 
cervical  adenitis.  I  have  seen  tuberculous  glands  of  large  size  tiisappear 
entirely  under  the  systematic  employment  of  this  agent,  but  it  should 
be  borne  in  mind  that  such  method  of  treatment  is  applicable  only  to 
carefully  selected  cases,  as  there  are  certain  limitations  and  restrictions 
even  to  its  special  emploj'ment.  Its  practical  utilit_v  is  dependent 
largely  upon  the  discrimination  exercised  concerning  the  character  of 
cases  to  which  it  is  applied.  Its  successful  u.se  does  not  depend  so 
much  upon  the  size  of  the  gland,  as  upon  the  nature  of  the  pathologic 
structure.  It  is  of  special  value  when  the  glands  are  firm,  adherent,  and 
devoid  of  any  apparent  inflammatory  condition.  In  the  presence  of 
softening  or  caseation,  however,  the  remedy  is  ineffective  and  involves 
an  unnecessary  delay  before  the  patient  is  accorded  the  benefit  of  much- 


TREATMENT    OF    GLANDULAR    TUBERCULOSIS  435 

needed  surgical  interference.  Under  such  conditions  there  is  no  pro- 
motion of  alDsorption  by  the  x-ray,  and,  therefore,  no  positive  diminution 
in  the  size  of  the  enlargement.  Inasmuch  as  it  is  sometimes  extremely 
difficult  to  determine  with  accuracy  the  pathologic  state  of  deep-seated 
tuberculous  glands,  it  follows  in  doubtful  cases  that  failure  to  secure 
positive  results  from  the  x-ray  after  a  few  weeks'  trial  should  be  accepted 
as  definitely  conclusive  of  their  inefficacy.  A  well-founded  suspicion 
of  softening  is  sufficient  to  contraindicate  even  its  initial  employment. 
The  value  of  x-ray  exposure,  however,  is  conceded  following  extirpation 
of  glands,  the  post-operative  treatment  being  worthy  in  all  cases  of 
careful  consideration.  Despite  a  seeming  thoroughness  of  the  oper- 
ation, a  glandular  swelling  not  uncommonly  reappears  in  the  imme- 
diate region  of  the  wound.  Such  possibility  is  somewhat  more  remote 
provided  several  exposures  of  the  x-ray  are  permitted  once  or  twice  a 
week  following  the  operation.  In  the  event  of  a  renewed  glandular 
enlargement  the  systematic  employment  of  the  x-ray  is  indicated  prior 
to  an  immediate  repetition  of  the  operation.  It  is  hardly  necessary 
to  add  that  treatment  by  this  method  should  be  received  only  at  the 
hands  of  a  skilled  and  experienced  radiographer.  Care  should  be  taken 
that  the  decision  concerning  the  character  of  the  treatment,  whether 
of  surgical  nature  or  by  means  of  the  x-ray,  should  not  be  made  upon  the 
basis  of  the  presence  or  absence  of  a  resulting  scar.  Too  often  parents 
and  physicians  are  prevailed  upon  to  discountenance  operation,  and 
elect  the  x-ray  form  of  management  through  fear  that  a  disfiguring  scar 
may  follow  complete  excision.  It  cannot  be  impressed  too  strongly  that 
this  is  an  entirely  subordinate  consideration,  and  should  have  no  place 
in  the  mind  of  the  medical  attendant  in  a  decision  as  to  the  choice  of 
procedure,  even  with  reference  to  the  female  sex.  As  a  matter  of  fact, 
unsightly  appearances,  especially  capillary  dilatations  in  the  form  of 
telangiectases,  sometimes  result  when  under  the  care  of  competent 
radiographers.  The  reader  is  referred  to  plate  1 1 ,  representing  the  dis- 
figurement occasionally  observed  from  the  use  of  the  x-ray. 

Upon  the  whole,  while  the  utility  of  the  x-raj'  for  the  treatment  of  a 
class  of  tuberculous  glands  has  been  fully  demonstrated,  its  exact  place 
from  a  therapeutic  standpoint  must  still  be  regarded  to  some  extent  as 
sub  judice. 

Surgical  Procedures. — Among  the  purely  surgical  procedures 
should  be  mentioned  especially  incision  with  drainage  and  complete 
extirpation. 

Aspiration  of  the  fluid  contents,  with  or  wdthout  the  later  injection 
of  various  preparations,  has  been  attended  with  almost  invariable  dis- 
appointment. Solutions  of  iodin,  phenol,  alcohol,  silver  nitrate,  guaia- 
col,  camphorated  naphthol,  balsam  of  Peru,  cinnamic  acid,  iodoform,  and 
zinc  chlorid,  when  injected  into  the  tissue  of  the  gland,  often  produce 
considerable  discomfort,  and  at  times  give  rise  to  dangerous  symptoms. 

Nearly  fifteen  years  ago  I  tried  in  several  instances  the  injection  of 
iodoform  dissolved  in  ether,  and  in  one  case  suspended  in  olive  oil,  with, 
upon  the  whole,  unsatisfactory  results.  At  best  this  practice  is  regarded 
as  unwarrantable.  It  is  distinctly  evasive  of  the  more  immediate  indi- 
cations, and  involves  a  continvied  waste  of  time,  which  sometimes  con- 
stitutes as  well  a  loss  of  opportunity. 

Simple  incision  is  indicated  in  cases  of  acute  glandular  tuberculosis 
exhibiting  unmistakable  evidences  of  softening.     As  soon  as  suppuration 


4d0  COMPLICATIONS 

occurs  and  is  rendered  possible  of  detection  by  fluctuation,  the  at 
however  small,  should  be  opened.  The  incision  should  be  of  no  greater 
length  than  necessary  to  insure  complete  evacuation  of  the  pus  and  sub- 
sequent drainage.  In  order  to  render  the  scar  but  slightly  conspicuous, 
surgeons  should  open  superficial  abscesses,  when  possible,  by  a  horizontal 
incision,  thus  insuring  its  concealment  by  the  collar.  The  horizontal  in- 
cision is  also  preferable  to  the  longitudinal,  for  the  reason  that  the  re- 
sulting scar  is  less  likely  to  be  reddened  and  hypertrophied  on  account 
of  the  diminished  traction  incident  to  the  frequent  turning  of  the  head. 
If  the  abscess  is  deep,  the  direction  of  the  incision,  however,  must  be 
determined  with  reference  to  the  position  and  course  of  the  blood-vessels, 
surgeons  prefering  an  olilique  downward  and  forward  incision  at  the 
upper  part  of  the  neck,  but  a  transverse  one  in  the  lower  portion.  Pre- 
caution should  be  taken  not  to  insert  the  knife  too  far  into  the  tissues 
of  the  neck.  Either  a  pair  of  blunt -pointed  scissors  or  a  grooved  cUrec- 
tor  should  penetrate  the  fascia  in  a  search  for  the  suppurating  cavity. 
After  the  insertion  of  the  scissors  or  forceps  into  the  abscess,  the  fascia 
should  be  torn  and  stretched  by  withdrawing  the  instrument  opened, 
thus  avoiding  the  danger  of  injury  to  immediate  structures. 

Curetment  is  sometimes  employed,  especially  in  cases  of  large  abscess 
formation,  and  is  particularly  applicable  to  gland  sinuses  with  a 
probable  mixed  infection.  When  prolongetl  anesthesia  and  radical 
surgical  intervention  is  precluded  by  the  general  condition,  it  is  occasion- 
all  .y  permissible  to  attempt  the  disintegration  of  glands  by  this  process,  the 
results  varying  according  to  the  thoroughness  with  which  the  glandular 
tissue  is  scraped  away.  To  remove  this  entirelj'  without  penetrating  the 
adherent  capsule  is  well-nigh  impossible,  while  considerable  traumatism 
may  result,  not  only  involving  possible  injury  to  immediate  blood- 
vessels, but  also  producing  a  rapid  extension  of  the  tuberculous  infection 
to  other  parts. 

Mayo  recommends  the  application  of  iodoform  emulsion  or  tincture 
of  iodin  following  incision  and  curetment,  and  an  immediate  closure  of 
the  incision  in  order  to  avoid  prolonged  drainage.  Sinuses  are  stimu- 
lated with  phenol  in  order  to  effect  as  complete  sterilization  as  possible. 
Gould  prefers  the  application  of  a  solution  of  zinc  chlorid,  40  grains  to 
the  ounce,  as  an  efficient  germicide.  In  many  cases  it  is  sufficient  to 
pack  lightly  the  cavity  wth  iodoform  gauze  for  a  few  days.  The  oper- 
ation is  simple,  necessitates  but  a  small  incision,  and  leaves,  as  a  rule, 
no  disfiguring  scar.  There  is  but  little  danger  of  penetrating  the  cap- 
sule and. injuring  veins,  arteries,  or  nerves.  pro\ided  a  blunt  spoon 
curet  is  employed.  The  deficiencies  of  the  operation  relate  to  its  un- 
reliability and  the  possibility  of  further  tulaerculous  extension. 

Total  excision  of  tuberculous  glands  is,  in  the  majority  of  instances, 
the  operation  of  choice.  This  time-honored  procedure  is  said  to  have 
originated  with  Galen,  and  to  have  lieen  employed  by  Par6.  It  is  of 
some  interest  to  note,  however,  that  for  several  hundred  years  up  to  the 
latter  part  of  the  nineteenth  century,  the  attempt  to  remove  enlarged 
glands  of  the  neck  was  quite  uniformly  deplored,  (^ooper,  in  1815, 
objects  to  the  practice  "  becavise  tlie  removal  of  a  scrofulous  gland  can 
hardly  be  said  to  do  much  good  to  a  patient  whose  whole  system  is 
under  the  influence  of  strumous  enlargement."  Druit,  in  his  "Modern 
Surgery,"  published  in  1841,  states  that  "it  is  sometimes  expedient  to 
extirpate  one  or  more  glands."  but  deprecates  such  effort  in  nearl_v  all 
cases.     Miller,  in  his  "  Principles  of  Surgery,"  published  in  1853,  says: 


TREATMENT  OF  GLANDULAR  TUBERCULOSIS 


437 


"It  is  almost  unnecessary  to  state  that  chronic  enlargements  of  lym- 
phatic glands  by  tuberculous  deposit  in  the  neck  are  not  to  be  made  the 
subject  of  severe  operation,  discussed,  they  may  be,  or  by  suppuration 
they  may  be  broken  down  and  extruded,  but  extirpation  is,  in  truth, 
but  reckless  and  unwarrantable  cruelty,  injurious  to  the  patient,  sur- 
geon, and  surgery."  Erichsen  and  Ashhurst,  in  1869,  state  that  "exci- 
sion of  enlarged  cervical  glands  is  seldom  necessary,  and  advise  against 
undertaking  the  operation  unless  the  disease  has  been  of  many  years' 
standing  and  the  glands  very  large."  In  1873  Hamilton,  in  his  "  Prac- 
tice of  Surgery,"  says:  "  Excision  has  in  all  cases  been  followed  by  a 
speedy  return.  After  the  most  thorough  extirpation,  new  glandular 
enlargements  have  soon  been  presented."  He  urges  the  limiting  of 
operation  to  cases  "in  which  only  one  or  at  most  only  a  few  adjacent 
glands  are  involved,  and  then  not  until  the  size  and  relation  of  the  tumor 
immediately  imperils  life."  In  1881  Savory  and  Roberts,  in  Holmes' 
"  System  of  Surgery,"  state:  "  Should  the  tuberculous  gland  be  removed 
by  operation?  Hardly  ever.  The  operation  can  be  justified  only  when 
the  glands  have  remained  for  a  very  long  time  stationary  in  spite  of  all 
local  measures  and  constitutional  treatment,  and  when  it  is  an  unsightly 
deformity  or  not  connected  with  diseased  glands  more  deeply  situated." 

Such  teaching  in  comparatively  recent  years,  denying  the  rationale 
of  complete  excision  of  tuberculous  glands,  is  somewhat  startling  in 
view  of  our  present  knowledge  regarding  the  relation  of  lymphatic 
enlargements  to  pulmonary  tuberculosis  and  general  miliary  infections. 
Groben,  after  an  analysis  of  the  statistics  of  several  clinicians,  reports 
that  pulmonary  tuberculosis  developed  in  75  per  cent,  of  all  non-operated 
cases,  and  in  less  than  15  per  cent,  of  tho.se  undergoing  excision.  The 
conclusions  of  other  observers  hardly  bear  witness  to  these  results,  but 
the  evidence  remains  irrefutable  that  the  proportion  of  cases  developing 
other  foci  of  tuljerculous  infection  is  much  larger  in  patients  denied  the 
benefit  of  active  surgical  interference.  In  this  connection  it  is  of  much 
interest  to  read  the  remarkable  words  of  John  Browne,  of  whom  mention 
has  been  previously  made,  apropos  of  healing  by  "royal  touch,' '  as  quoted 
by  Stoll.  In  the  seventeenth  century  he  says:  "  These  tumors  do  require 
extirpation  and  extraction.  .  .  .  to  be  so  dexterously  performed  as 
that  no  part  be  left  behind.  .  .  .  Our  greatest  advice  in  the  use  of 
the  knife  is  to  have  a  particular  and  special  care  to  the  vessels  bordering 
upon  the  parts,  namely,  the  nerves,  veins,  ;ni(l  aileries,  lest  they  be 
injured  thereby.  The  glands  are  to  be  cxt  i^i.lcd  with  great  care  and 
caution,  so  as  no  ve.s.sel  whatsoever  be  injured  l>y  tlie  operation;  and  if 
any  flux  of  blood  may  happen  in  this  operation,  it  is  presently  to  be 
stopped  with  restrictives,  and  this  method  is  to  be  prosecuted  till  every 
part  of  the  cystus  or  bags  thereof  are  perfectly  and  thoroughly  eradicated 
and  extracted,  the  which  being  done  and  the  part  clean,  mundifie  the 
ulcer,  digest,  incarn  and  then  induce  a  cicatrix." 

It  is  scarcely  witliin  the  province  of  this  book  to  elaborate  the  technic 
of  the  operation.  It  is  sufficient  merely  to  call  attention  to  several 
important  considerations  in  connection  with  the  principles  of  surgery 
as  applied  to  glandular  tuberculosis. 

A  large  proportion  of  cases  of  cervical  adenitis  are  suited  to  radical 
operation.  The  existence  of  a  moderate  pulmonary  infection  does  not  in 
itself  offer  any  distinct  contraindication  for  operative  interference.  If  the 
pulmonary  involvement  is  not  far  advanced,  the  indications  for  oper- 


438  COMPLICATIONS 

ation  are  emphasized  by  the  very  fact  of  its  existence.  Added  oppor- 
tunities for  recovery  are  offered  by  virtue  of  the  removal  of  an  important 
and  often  primary  focus  of  infection.  The  supposed  danger  of  anes- 
thesia to  the  consumptive  has  been  found  by  actual  experience  to  be 
largely  a  myth.  I  do  not  recall  a  single  instance  of  unfortunate  results 
of  chloroform  or  ether  anesthesia  among  the  many  phthisical  patients 
undergoing  operation  for  various  causes. 

Complete  extirpation  of  tuberculous  glands  is  often  one  of  the  most 
difficult  and  techous  operations  which  the  surgeon  is  called  upon  to 
perform.  It  should  not  l)e  undertaken  by  other  than  those  possessing 
an  excellent  technic  and  thorough  familiarity  with  the  anatomic  rela- 
tions. A  most  important  con.sideration  is  the  complete  and  thorough 
removal  of  all  affected  glands.  To  this  end  search  must  be  made 
patiently  and  carefully  in  the  midst  of  highly  important  structures 
for  almost  innumerable  glands  not  originally  detected. 

Much  has  been  written  about  the  advantages  and  cUsadvantages 
of  the  various  forms  of  incision.  Some  surgeons  recommend  several 
small  ones,  either  oblique  or  transverse;  others  urge  large  sweeping 
incisions,  either  of  the  letter  Z  or  letter  S  shape,  or  conforming  to  a 
simple  transverse  curve  across  the  upper  portion  of  the  neck.  No 
conventional  incision  is  applicable  to  all  cases.  The  essential  desider- 
atum is  to  have  plenty  of  room,  and  this  demands  a  large  opening, 
extending  in  many  cases  from  the  mastoid  to  the  clavicle,  regardless 
of  subsequent  deforming  cicatrix.  To  avoid  injury  to  important  parts 
the  dissection  should  be  made  as  much  as  possible  with  a  blunt  instru- 
ment. Care  should  be  taken  to  remove  the  glands  intact  without  rup- 
ture of  their  capsule,  in  order  to  prevent  all  danger  of  disseminating  the 
infection  through  contamination  of  the  wound.  This  possibility, 
together  with  the  danger  of  injury  to  nerves  and  blood-vessels,  repre- 
sents one  of  the  cUsadvantages  of  the  operation.  Its  thoroughness, 
however,  more  than  offsets  any  objections  incident  to  its  severity.  It 
is  essential  to  remove  with  a  wide  excision  all  gland-l^earing  fascia.  A 
subcuticular  suture  will  lessen  the  prominence  of  the  scar. 

Further  discussion  of  the  surgical  details  is  inappropriate  in  connec- 
tion with  a  work  devoted  to  pulmonary  tuberculosis.  It  is  permissible 
to  allude  briefly  to  the  danger  of  wounding  veins,  arteries,  and  nerves. 

The  chief  parts  liable  to  injury  are  the  jugular  vein  and  the  spinal 
accessory  nerve,  together  mth  the  pneumogastric,  phrenic,  laryngeal, 
sympathetic,  and  the  facial. 

A  somewhat  unique  accident,  occurring  in  the  course  of  oper- 
ation, came  under  my  observation  seven  years  ago.  A  young  man 
consulted  me  in  January,  1900,  with  reference  to  a  tuberculous  enlarge- 
ment upon  the  right  side  of  the  neck  the  size  of  a  hen's  egg.  He 
had  been  operated  upon  in  1891  by  Dr.  W.  T.  Bull,  who  removed  a 
large  ma.ss  from  the  left  side.  I  advised  immediate  operation  for  the 
right-sided  involvement,  and  referred  the  patient  to  Dr.  Powers.  The 
patient,  however,  after  some  delay  submitted  to  operation  at  the  hands 
of  a  surgeon  in  another  locality.  I  was  not  present  at  the  operation,  but 
was  informed  subsequently  that  there  was  profuse  hemorrhage  and  that, 
by  means  of  an  aneurysm  needle,  the  deep  ves.sels  were  tied  with  heavy 
silk  ligatures.  It  was  found  impossible  to  complete  the  operation  after 
this  on  account  of  the  collapse  of  the  patient.  Upon  recovery  from  the 
anesthetic  there  were  distre.s.sing  spasmocUc  cough  and  aphonia.  The 
severe  cough  was  practically  constant  for  several  days,  while  the  loss  of 


TREATMENT  OF  GLANDULAR  TUBERCULOSIS  439 

voice  persisted  for  some  weeks.  After  a  gradual  subsidence  the  cough 
was  quickly  excited  at  all  times  by  gentle  pressure  in  the  region  of  the 
wound.  About  five  weeks  subsequent  to  the  operation  the  patient 
again  came  under  observation  and  the  further  management  was 
directed  by  Dr.  Powers,  who  reported  the  case  at  length.  On  ac- 
count of  the  unsatisfactory  condition  of  the  patient,  it  was  not 
thought  wise  to  attempt  any  surgical  interference  until  January  of  the 
following  year.  Powers  reports:  "The  scar  on  the  right  side  of  the  neck 
was  exceedingly  irritable,  even  slight  pressure  at  any  point  in  its  upper 
third  occasioned  severe  spasmodic  coughing.  Nearly  a  year  following 
the  previous  operation  the  end  of  a  heavy  silk  ligature  presented  at  the 
upper  end  of  the  sinus.  Traction  with  an  artery  clamp  occasioned 
intense  coughing,  pain,  shortness  of  breath,  and  vomiting."  During  the 
operation,  which  followed  shortly,  the  loop  of  the  ligature  was  found 
surrounding  a  large  mass  of  granulation  tissue,  in  the  midst  of  which 
lay  the  pneumogastric  nerve.  "The  slightest  interference  with  this 
portion  of  the  wound  and  the  slightest  traction  of  the  ligature  brought 
on  alarming  coughing  and  cyanosis."  The  patient  made  a  good  recovery. 
Some  months  after  the  operation  the  tendency  to  cough  upon  pressure 
at  the  site  of  the  wound  almost  disappeared.  During  the  last  few 
years  his  recovery  has  seemed  apparently  complete,  until  a  recent 
appearance  of  glandular  enlargement,  for  which  the  bacilli  emulsion  is 
bein;";  administered  at  the  present  time. 

The  tendency  to  recurrence  should  always  be  borne  in  mind.  Mayo 
has  pointed  out  that  the  term  recurrence  is  used  improperly  in  that  the 
enlargement  is  due  to  the  growth  of  new  glands,  rather  than  to  an 
impossible  re;i.i>i)oaiaiico  of  glands  once  removed.  It  should  be  made 
clear  to  the  patient  and  friends  that  the  excision  of  enlarged  glands 
offers  no  positive  assurance  that  other  glandular  structures  previously 
quiescent  may  not  come  to  the  front  in  due  time,  and  present  them- 
selves in  the  neighborhood  of  the  former  site.  The  percentage  of  recur- 
rences varies  from  about  25  to  70,  as  reported  by  several  observers. 
Mayo  reports  that  during  the  past  four  years  there  have  been  operated 
in  Rochester  235  cases  for  primary  tuberculous  enlargement  of  the 
glands,  and  but  15  cases  for  secondary  involvement. 

The  return  of  the  trouble  is  not  always  due  to  a  lack  of  skill  or  knowl- 
edge on  the  part  of  the  operator  at  the  time  of  the  initial  operation, 
nor  is  it  dependent  necessarily  upon  an  impaired  condition  of  the  patient. 

I  recall  the  case  of  a  young  man  who  consulted  me  in  1896,  imme- 
diately upon  arrival  in  Colorado,  on  account  of  moderately  enlarged 
tuberculous  glands  of  the  left  side  of  the  neck.  There  was  no  evidence 
of  tuberculous  lesion  elsewhere,  the  general  condition  was  unusually 
robust,  the  patient  was  plethoric,  and  nutrition  was  unimpaired.  An 
operation  which  lasted  several  hours  was  performed  very  patiently  and 
skilfully  by  Dr.  Edmund  J.  A.  Rogers.  During  the  next  few  years  four 
different  operations  were  performed  by  the  same  surgeon  for  enlarged 
tuberculous  glands  upon  each  side  of  the  neck,  the  general  condition 
remaining  unimpaii'ed,  with  no  evidence  of  tuberculous  infection  in 
other  parts  of  the  body.  Enlarged  glands  continued  to  appear,  how- 
ever, with  but  little  delay,  following  each  operation,  and  there  finally 
developed  an  acute  miliary  infection  which  terminated  his  suffering. 

It  is  a  reasonable  assumption  that  had  this  case  been  observed  after 
the  discovery  of  the  x-rays,  better  results  might  possibly  have  been 
obtained  from  their  employment  as  a  postoperative  procedure. 


COMPLICATIONS 


SECTION   V 
Tuberculosis  of  Bones  and  Joints 


CHAPTER  LXIII 
ETIOLOGIC  AND  PATHOLOGIC  CONSIDERATIONS 

The  etiology  of  tuberculosis  of  the  bones  and  joints  is  not  especially 
different  in  its  essential  characteristics  from  the  conditions  giving  rise 
to  involvement  of  other  parts  of  the  body. 

The  pathologic  condition  is  due  primarily  to  the  presence  of  the 
tubercle  bacillus  in  the  affected  part,  although  the  manner  of  its  introduc- 
tion to  the  seat  of  the  disease  is  not  always  entirely  clear.  A  somewhat 
obscure  conception  as  to  the  precise  method  of  infection,  arises  by  virtue 
of  the  supposed  protection  of  the  parts  from  an  anatomic  standpoint, 
the  dense  structure,  the  frequent  sharp  localization  of  the  diseased  area, 
and  the  failure  to  discover  a  possible  neighboring  focus  of  tuberculous 
infection.  Further  confusion  results  from  the  promulgation  of  the 
theory  of  a  strong  hereditary  influence  in  determining  the  development 
of  the  disease.  The  acceptance  of  certain  clinical  data  also  affords 
ground  for  -nidely  tUffering  opinions  regarding  the  etiology.  It  is  well 
known  that  the  great  majority  of  cases  of  tuberculosis  of  bones  and 
joints  develop  in  early  life. 

Billroth  reports  one-third  of  all  cases  to  have  occurred  during  the 
first  ten  years  of  life,  and  one-half  before  the  twentieth  year.  Wliitman 
reports,  out  of  a  total  of  .5461  cases  of  tuberculous  di.sease  under  treat- 
ment at  the  Hospital  for  Ruptured  and  Crippled,  that  seven-eighths  of 
the  patients  were  under  fourteen  years  of  age  and  that  85  per  cent,  of 
those  recently  treated  were  in  the  first  decade  of  life.  The  fact  remains, 
however,  that  it  not  uncommonly  develops  among  apparently  strong 
and  healthy  individuals  without  any  evidence  of  preexisting  tubercu- 
lous disease  or  other  assignable  cause.  I  have  had  occasion  to  note, 
in  a  rather  surprising  number  of  cases,  the  .so-called  idiopathic  devel- 
opment of  tuberculous  processes  in  bones  and  joints  among  adult 
robust  farmers  and  others  accustomed  to  physical  acti\aty  in  the  open 
air. 

The  r61e  of  trauma,  with  or  without  penetrating  wounds,  consti- 
tutes another  etiologic  phase  susceptible  perhaps  of  varying  interpreta- 
tions. Slight  concussion  without  visible  wountl  has  been  followed  by 
distinct  infective  processes,  w'hile  severe  contu.seel  or  penetrating  injuries 
have  often  occasioned  no  evidence  of  tuberculous  bone  lesions  despite 
the  pre.sence  of  apparently  similar  conditions. 

Incised  wounds  have  been  known  to  heal  promptly  with  the  speedy 
subsequent  appearance  of  a  localized  tuberculous  process  in  iniiividuals 
presenting  every  external  appearance  of  vigorous  health.  On  the  other 
hand,  invalids  with  advanced  pulmonary  tulierculosis  rarely  develop 
bone  or  joint  lesions.  Further,  the  parts  most  frequently  affected  are 
those  least  liable  to  external  injury.      Tuberculous  lesions  of  the  lower 


ETIOLOGIC    AXD    PATHOLOGIC    CONSIDERATIONS  441 

extremities  are  observed  much  more  often  tlian  of  the  upper,  although 
the  latter  are  far  more  likely  to  undergo  injury. 

Upon  the  basis  of  the  above  established  truths  it  is  somewhat  diffi- 
cult to  formulate  a  consistent  theory  as  to  the  precise  method  of  invasion 
of  bones  and  joints  capable  of  application  to  all  cases. 

A  studious  analysis  of  the  available  data  upon  which  to  base  con- 
clusions justifies  the  assumption  that  in  the  majority  of  instances  the 
affection  of  the  bones  is  secondary  to  an  antecedent  tuberculous  focus, 
and  that  the  involvement  of  the  joints  is  in  most  cases  a  simple  peri- 
pheral extension  from  a  tuberculous  osteitis.  It  is  undoubtecUy  true, 
however,  that  local  tuberculous  processes  may  sometimes  originate 
within  the  joint  without  previous  involvement  of  the  bone.  Primary 
tuberculosis  of  the  synovial  membrane  is  described  by  various  observers, 
and  is  believed  to  be  a  not  uncommon  condition  of  the  knee-joint  in 
adults.  It  is  reasonable  to  assume,  however,  from  the  observations  of 
Nichols,  that  painstaking  investigation  would  disclose  the  presence  of 
foci  in  the  osseous  tissues  antedating  tlie  joint  involvement.  Contrary 
to  the  opinion  entertained  by  many  that  the  infective  material  is 
conveyed  to  the  part  through  the  circulatory  channels,  it  is  held  that 
the  route  chiefly  traversed  by  the  bacilli  is  along  the  lymphatics.  Were 
the  vascular  system  the  chief  medium  for  the  distribution  of  the  infective 
agent,  it  would  be  natural  to  expect  a  more  general  involvement. 
Neither  failure  to  discover  a  previous  tuberculous  focus  in  the  neighbor- 
hood of  a  bone  or  joint  lesion,  nor  absence  of  a  visible  infection  atrium 
in  the  skin  affords  any  valid  argument  in  favor  of  the  primary  nature  of 
the  process. 

That  infections,  metastatic  in  character,  may  take  place  in  these 
parts  via  the  lymphatics  and  circulatory  systems  is  illustrated  by  the 
observation  of  joint  disturbances  in  rheumatism,  gonorrhea,  and  toxic 
arthritis. 

However,  in  all  these  affections  the  frequent  localization  of  the 
process  in  a  single  joint  strongly  suggests  the  rather  predominant  in- 
fluence of  the  lymphatics  as  compared  with  the  vascular  channels.  It 
is  scarcely  necessary  to  recognize  definitely  the  site  and  method  of  inva- 
sion or  to  demonstrate  the  presence  of  antecedent  tuberculous  foci  as 
points  of  departure  of  l^one  and  joint  lesions,  in  order  to  substantiate 
their  secondary  character.  It  has  been  shown  in  previous  chapters 
that  glands  may  present  every  external  appearance  of  a  normal  condition, 
and  yet  contain  imprisoned  bacilli  constituting  latent  foci  of  infection. 
It  is  easy  to  conceive  that  under  a  quickly  developing  inflammation 
attending  such  acute  infectious  diseases  as  diphtheria,  measles,  scarlet 
fever,  and  whooping-cough,  the  glandular  tumefactions  may  be  suffi- 
cient to  produce  a  rupture  of  the  capsule,  giving  rise  to  further  tuber- 
culous dissemination,  and  yet  disclose  no  subsequent  macroscopic 
evidence  of  involvement. 

Cornet  has  quoted  the  results  of  67  autopsies  performed  by  Konig- 
Orth.  In  53  cases,  or  79  per  cent.,  there  were  found  tuberculous  lesions 
besides  the  bones  and  joints,  but  in  14  cases  no  other  tuberculous  foci 
were  discovered.  The  lungs  were  involved  in  37  instances,  the  glands  in 
21,  and  the  genito-urinary  apparatus  in  9.  He  also  cites  Bollinger's  and 
Unger's  statistics  with  respect  to  the  frequency  of  hereditary  transmis- 
sion, the  former  reporting  a  direct  inherited  taint  in  97  out  of  2.50  cases, 
the  latter  in  11  out  of  54.     These  proportions  are  much  smaller  than  the 


442  COMPLICATIONS 

reported  experience  of  many  observers.  In  Bollinger's  statistics  a  his- 
tory of  tuberculosis  was  inclusive  of  the  four  grandparents,  as  well  as 
the"  father  and  mother.  The  frequency  of  tuberculosis  in  the  parents  of 
children  afflicted  with  bone  or  joint  lesion  is  certainly  much  greater 
among  the  cases  that  I  have  been  permitted  to  observe  in  Colorado. 
I  can  recall  but  few  instances  of  bone  or  joint  infection  in  children  up  to 
seven  or  eight  years  of  age,  one  of  whose  parents  was  not  the  subject  of 
a  non-arrested  pulmonary  tuberculosis  at  the  birth  of  the  child.  In 
almost  every  case  in  which  this  was  not  true  one  or  both  parents  were 
victims  of  some  other  cUsorder  impoverishing  nutrition  and  gi'eatly  im- 
pairing vitality.  The  theory  that  the  influence  of  herecUty  relates  to  a 
diminished  cell  resistance  rather  than  an  imparted  disease  is  not  restricted 
in  its  application  to  the  existence  of  tubercido.sis.  It  is  clear  that  a  de- 
ficient vitalization  with  increased  vulnerability  of  tissue  may  be  imparted 
at  the  time  of  conception  as  a  result  of  other  debilitating  conditions. 
During  the  first  few  years  of  life,  at  the  very  age  when  glandular  tuber- 
culosis is  most  likely  to  develop,  the  combative  phagocytic  power  of  the 
ceils  is  less  pronounced  than  after  growth  has  been  attained.  The  child 
has  emerged  from  the  successive  periods  of  undue  susceptibility  occa- 
sioned by  repeated  digestive  cUsturbances  and  acute  inflammatory  con- 
ditions of  the  nose  and  pharjmx,  inclucUng  hypertrophied  tonsils  and 
adenoids.  Finally  measles,  pertussis,  scarlet  fever,  bronchopneumonia, 
recurring  bronchitis,  and  influenza  produce  a  general  enfeeblement  of  the 
system,  and  excite  latent  tuberculous  foci  to  renewed  activity.  In  other 
words,  the  occurrence  of  tuberculous  bone  and  joint  lesions  during  early 
life  is  the  direct  and  demonstrable  result  of  a  preexisting  focus  of  infec- 
tion, from  which  points  of  departure  are  jjermitted  through  lowered  indi- 
vidual resistance.  At  this  age  the  latency  of  tuberculous  infections  is 
maintained  with  more  tlifficulty,  as  the  natural  constructive  processes  are 
less  pronounced,  the  lymph-spaces  more  permeable,  allowing  more  ready 
distribution  of  bacilli,  and  the  vulnerability  of  the  tissues  definitely 
increased.  The  prevalence  of  tuberculosis  in  infancy  and  childhood, 
together  with  its  excessive  fatality,  affords  a  priori  a  rather  convincing 
argument  as  to  the  verity  of  Behring's  theory  regarding  infection  through 
the  intestinal  tract  at  this  age,  and  in  many  cases  the  persistence  of 
latent  foci  to  adult  life. 

The  origin  of  local  bone  and  joint  tuberculosis  in  adult  years  is 
often  traceable  to  trauma.  Whitman  alludes  to  the  experience  of 
Hildebrand,  Konig,  Mikulicz,  and  Bruns.  who  report,  out  of  a  total  of 
3398  ca.ses  of  osseous  and  joint  tuberculosis,  513  properly  attributable 
to  trauma.  Krause  has  shown  that  the  cancellous  tissue  is  made 
more  vulnerable  to  the  action  of  tubercle  bacilli  following  an  injury. 
In  but  exceptional  cases,  however,  is  there  afforded  througii  this  means 
a  tUrect  gateway  of  infection.  It  may  be  assumed  as  an  almost  univer- 
sal condition  that  a  means  of  invasion  had  already  been  established 
through  some  other  channel,  and  that  the  cellular  resistance  had  thus 
far  been  sufficient  to  hold  the  infection  in  abeyance. 

Through  the  influence  of  slight  traumatism  the  defensive  power  of 
the  tissue-cells  is  diminished  by  virtue  of  the  new  inflammatory  con- 
chtion.  If  the  injuiy  is  severe,  however,  the  in\aders  are  repelled 
more  readily  as  a  result  of  the  increased  resistance  incident  to  the 
excessive  local  congestion  arising  from  the  trauma.  In  this  event  the 
increased  phagocytosis  is  somewhat  analogous  to  that  attencUng  the 


ETIOLOGIC    AND    PATHOLOGIC    CONSIDERATIONS  443 

congestion  produced  by  the  so-called  Bier  treatment  of  chronic  inflam- 
mation of  the  joints. 

The  order  of  frequency  of  tuberculous  lesions  of  the  bones  and  joints, 
established  by  a  review  of  the  statistical  reports  of  various  institutions, 
shows  the  vertebrae  to  be  affected  in  nearly  one-half  of  all  the  cases,  the 
hip-joint,  in  from  30  to  35  per  cent.,  with  involvement  of  the  knee, 
ankle,  wrist,  elbow,  and  shoulder  decidedly  less  frequent. 

The  microscopic  pathology  of  bone  and  joint  tuberculosis  is  not 
essentially  dissimilar  to  that  obtaining  in  other  parts  of  the  body, 
although,  owing  to  the  greater  density  of  the  histologic  structures,  the 
process  is  of  slower  development  than  tuberculous  lesions  elsewhere. 
Circumscribed  tuberculous  nodules  composed  of  individual  tubei-cles  are 
produced.  Within  the  tubercle  deposit  are  found  cells  of  various  shape, 
the  epithelioid  variety  usually  predominating.  Masses  of  polynucleated 
giant-cells  are  also  present.  Bacilli  are  observed  both  within  and  with- 
out the  various  cells.  Round-cells  are  numerous  within  the  tuberculous 
structure.  With  increasing  development  of  the  tubercle,  which  takes 
place  by  extension  in  the  periphery,  retrograde  changes  occur  in  the 
center.  With  the  appearance  of  polynucleated  leukocytes  a  degener- 
ative process  supervenes,  followed  by  caseation  and  softening.  As  a 
result  of  the  coalescence  of  numerous  tubercles,  each  undergoing  in  the 
center  degenerative  change  and  softening,  aliscess  formation  eventually 
takes  place.  The  suppurative  procrss  rcincsciits,  therefore,  the  center 
of  the  entire  tuberculous  mass,  while  a  new  tuberculous  development 
takes  place  at  the  outer  margins.  Supjiuralidn  results  not  solely  from 
the  action  of  the  tubercle  bacilli,  but  often  fidiii  tlie  added  presence  of 
some  other  microorganism,  notably,  the  staiihyldciH  riis.  The  develop- 
ment of  secondary  or  mixed  infection  is  usually  attended  by  greater 
infiltration  of  adjacent  tissues  and  increased  suppuration. 

Fibrous  tissue  metamorphosis  sometimes  occurs,  inducing  varying 
periods  of  quiescence  of  the  tuberculous  process.  This  may  con- 
tinue as  a  partially  arrested  degenerative  change  in  the  bony 
structure,  undergo  calcification,  or  finally  remain  encapsulated  as 
a  cold  abscess.  Through  the  influence  of  an  aggi'essive  phagocytosis 
the  destructive  progress  of  the  tuberculous  bone  lesion  is  sometimes 
interrupted.  On  the  other  hand,  the  tubercle  deposit  may  produce 
softening  and  subsequent  absorption  of  the  bony  trabeculse.  With  in- 
creasing formation  of  granulation  tissue  there  ensues  an  osseous  necrosis. 
Caries  of  bone  thus  established  is  associated  with  the  detachment  of 
destroyed  portions  which  takes  place  either  in  small  particles  or  in  the 
separation  of  a  definite  sequestrum. 

As  a  rule,  the  tuberculous  deposit  occurs  primarily  in  the  short 
bones  or  in  the  extremities  of  the  long  bones.  When  the  short  bones 
are  attacked,  especially  the  phalanges  and  metacarpi,  the  tuberculous 
infiltration  involves  the  medullary  tissue,  giving  rise  to  the  term  tuber- 
culous  osteomijelitis.  In  the  long  bones,  as  the  femur  and  tibia,  the 
deposit  of  tuberculous  material  takes  place,  as  a  rule,  in  the  epiphysis 
or  immediately  adjacent  to  it.  In  caries  of  the  ribs  and  vertebrae  the 
initial  tuberculous  involvement  is  directly  beneath  the  periosteum,  pro- 
ducing erosion  and  sometimes  extensive  destruction  of  the  osseous  tissue. 
Bone  tuberculosis  occurring  as  a  part  of  an  acute  general  miliary  infec- 
tion has  but  slight,  if  any,  clinical  interest. 

The  process  originating  in  the  epiphysis  of  the  long  bones  extends 


444  COMPLICATIONS 

peripherally  in  all  directions,  and  often  advances  to  the  articular  or 
joint  surface.  The  entire  cartilaginous  attachment  occasionally  becomes 
loosened  and  separated  en  inas.sc  from  the  bone.  In  the  event  of  infec- 
tion of  the  sjaiovial  membrane  there  results  a  chffused  infiltration  of  the 
surface  and  occa.sional  nodular  formation.  With  further  degenerative 
change  there  is  foimd  a  deposit  of  tuberculous  granulations,  with  erosion 
of  the  cartilage,  and  progressive  infection  of  neighboring  tissues  as  a 
result  of  the  capsule  perforation.  After  this  has  taken  place  the  second- 
ary changes  in  adjacent  structures  partake  of  fibrous  tissue  proliferation, 
which  results  in  greater  or  less  fusing  of  the  muscles  and  tendon-sheaths, 
thus  retarding  still  further  the  mobility  of  the  joint.  In  adchtion  to  ad- 
hesions produced  by  the  organization  of  fibrinous  deposits  there  often 
ensues  the  formation  of  bony  new-growth  from  periosteal  irritation. 
Fluid  may  accumulate  in  the  joint  in  varj-ing  amounts,  the  exudate 
containing  broken-tlown  caseous  material  and  sometimes  flocculent 
coagula.  Attention  is  called  to  the  widely  varying  character  of  the 
joint  lesions,  which,  as  previously  stated,  are  sometimes  apparently 
primary  in  character. 

Both  the  prognosis  and  treatment  are  largely  dependent  upon  the 
extent  and  character  of  the  tuberculous  involvement  of  the  articular  sur- 
face. In  proportion  as  the  synovial  membrane  of  the  articulation  is 
thickened  and  the  cartilage  perforated  will  there  be  increased  restric- 
tion of  motion,  added  cUfficulty  in  securing  arrest,  and  increasing  dan- 
ger of  subsequent  tuberculous  cUssemination  through  the  retention  of 
infective  general  detritus. 


CHAPTER   LXIV 


CLINICAL  MANIFESTATIONS  OF  BONE  AND  JOINT 
TUBERCULOSIS 

Early  Symptoms. — The  symptoms  of  bone  and  joint  tuberculosis 
are  worthy  of  separate  consideration.  The  early  manifestations  of 
osseous  tuberculosis  affecting  the  long  bones  are  often  exceedingly 
indefinite.  A  sense  of  vague  cUscomfort  in  the  limb  is  frecjuently  exper- 
ienced as  an  initial  symptom.  An  enlargement  of  the  bone  is  noted 
which  is  usually  unilateral.  Moderate  tenderness  is  often  present,  and 
when  marked  over  a  circumscribed  region,  abscess  formation  external 
to  the  bone  may  be  suspected.  Tuberculous  enlargement  of  the  small 
bones,  especially  the  phalanges,  is  often  capable  of  very  early  recog- 
nition, the  shape  of  the  fingers  being  exceedingly  characteristic. '  The 
affection  is  seldom  confined  to  a  single  finger,  the  phalanges  are  chs- 
tinctly  spindle  sluxped,  conforming  to  the  appearance  commonly  ob- 
served in  hereditary  sj-philis,  but  the  latter  condition,  as  a  rule, 
may  be  excluded  by  the  absence  of  associated  evidences  of  a  specific 
taint.  There  is  rarely  pain,  and  but  occasional  abscess  formation,  in 
this  variety  of  bone  tuberculosis. 

In  tuberculous  periostitis  affecting  the  rib,  pain  is  sometimes,  though 
not  always,  experienced.     Suppuration  is  almost  constant,  and  a  small 


CUNICAL    MANIFESTATIONS    OF    BONE    AND    JOINT    TUBERCULOSIS      445 

localized  tumor  is  recognized.     The  skin  is  rec'dened,  and  fluctuation 
is  present. 

In  joint  tuberculosis  the  swelling  and  pain  may  be  acute  in  some 
cases  and  almost  entirely  absent  in  others.  The  pain  may  even  be 
referred  to  points  remote  from  the  affected  joint.  The  symptoms  are 
largely  dependent  upon  the  degree  and  nature  of  the  pathologic  change 
upon  the  articular  surface.  Complaint  may  be  made  at  first  of  but 
mere  uneasiness  or  discomfort  of  the  limb,  without  especial  localization 
in  the  joint,  this  being  particularly  true  of  hip  disease.  As  the  disease 
progresses  an  effusion  takes  place,  and  limitation  of  motion,  together 
with  actual  pain,  results  upon  movement  of  the  joint  or  the  imposition 
of  weight.  Swelling  of  the  affected  articulation  is  noted  upon  in- 
spection, together  with  a  relative  increase  of  heat  upon  palpation  in 
comparison  with  the  corresponding  joint  of  the  other  side.  In  adchtion 
to  the  physical  evidences  of  synovial  effusion  sometimes  present  a 
general   inflammatory   condition,   commonly   described  as   doughy,   is 


Fig.   114.— Cicat 


recognized  in  the  immecUate  neighborhood  of  the  joint.  More  or  less 
deformity  takes  place,  and  the  limb  assumes  a  position  of  partial  flexion. 
Reflex  pains  are  now  more  pronounced,  though  local  tenderness  is  usually 
present.  As  the  morbid  changes  within  the  joint  advance  to  perforation 
or  increased  thickening  of  the  membrane  and  cartilage,  abscess  formation 
results  and  even  ankylosis. 

Generally  speaking,  the  diagnosis  of  tuberculous  joint  lesions  in  chil- 
dren is  confounded  principally  with  that  of  rheumatism.  Unfortunately, 
the  tendency  is  quite  common  to  regard  many  of  these  cases  as  instances 
of  simple  rheumatism,  and  much  valuable  time  is  lost  before  the  patient 
receives  the  benefit  of  rational  management.  It  should  be  remembered 
that  single  joint  inflammation  in  children  points  strongly  toward  a  lesion 
of  tuberculous  character.  The  slow  onset,  without  immediate  temper- 
ature elevation  or  acceleration  of  pulse,  together  with  flexion  of  joint 
and  muscular  rigidity,  also  are  almost  conclusive  evidences  of  tubercu- 
lous joint  disease. 


446  (  OMPLICATIOXS 

The  prognostic  considerations  relate  to  the  danger  of  further 
dissemination  of  the  tuberculous  infection,  directly  endangering  life, 
and  to  the  character  of  the  local  changes  involving  deformity,  impaired 
function,  and  injury  to  neighboring  structures.  The  probability  of  ex- 
tension of  the  tuberculous  infection  from  bone  and  joint  lesions  is  con- 
siderably less  than  the  likelihood  of  dissemination  from  primary  foci  in 
the  lymphatic  glands  and  lungs.  The  influence  of  tuberculous  joint 
lesions  upon  the  ultimate  prognosis  is,  of  course,  dependent  largely  upon 
the  location  of  the  diseased  area,  involving  a  separate  consideration  of 
the  affected  joints. 

It  is  manifeistly  impossible  in  a  book  of  this  character  to  consider 
at  length  the  clinical  aspects  of  tuberculous  affections  of  the  various 
parts  of  the  body.  It  is  sufficient  to  call  brief  attention  to  some  of  the 
more  salient  features  of  caries  of  the  spine  and  tuberculosis  of  the  hip- 
and  knee-joints. 

Caries  of  the  spine,  consisting  of  tuberculous  involvement  of  the 
anterior  portion  of  the  body  of  the  vertebra  in  various  portions  of  the 
spinal  column,  is  not  only  more  frequent  than  other  varieties  of  bone  and 
joint  tuberculosis,  but  is  relatively  more  important.  This  is  due  to  the 
pro.ximity  of  the  cUseased  area  to  highly  important  structures.  The 
results  of  the  affection  are  not  confined  in  all  cases  to  the  immediate 
neighborhood  of  the  tuberculous  process.  In  some  instances  not  only 
the  thoracic  and  abdominal  organs  are  involved,  but  often  the  entire 
body. 

The  extent  and  character  of  the  deformity  and  the  degree  of  com- 
pres.sion  of  vital  organs  depend  to  a  great  extent  upon  the  precise  location 
of  the  disease  in  the  spinal  column — the  nearer  the  middJe  of  the  spine, 
the  greater  and  more  unfortunate  the  deformity.  The  dorsolumbar 
region  is  the  portion  most  frequently  affected.  The  proportion  of 
involvement  of  the  various  regions  of  the  spine  is  in  the  neighborhood 
of  60  per  cent,  for  the  dorsal,  25  to  30  per  cent,  for  the  lumbar,  and  7  to 
12  per  cent,  for  the  cervical. 

A  concise  review  of  the  symptoms  and  signs  of  early  Potfs  disease 
should  be  of  special  interest  to  the  general  practitioner.  The  prevention 
of  deformity  and  of  the  resulting  eompres.sion  of  the  thoracic  and  abdom- 
inal organs,  with  impairment  of  vital  functions,  is  almost  entirely  depend- 
ent upon  the  early  recognition  of  the  condition.  An  angular  projection 
has  ever  been  regarded  as  the  chief  characteristic  sign  of  Pott's  disease, 
and  the  diagnosis  has  often  been  delayed  until  the  enforced  detection, 
by  this  means,  of  a  destructive  process  already  considerably  advanced. 
As  a  matter  of  fact,  the  earlj'  symptoms  of  the  disease  are  sufficiently 
characteristic  to  permit  a  positive  conclusion  as  to  the  nature  of  the 
affection  long  before  there  is  encountered  irregularity  in  the  con- 
tour of  the  spine.  Occasional  complaint  is  made  of  pain  produced  by 
sudden  jars,  and  referred  not  to  the  region  of  the  vertebrae,  but  to  the 
abdomen  or  thighs.  This  is  often  pronounced  at  night  as  a  result  of 
involuntary  muscular  movement. 

Upon  examination  of  the  spine  an  impaired  mobility  is  at  once 
detected,  and  constitutes  a  mo.st  important  diagnostic  feature.  The 
stiffness  is  produced  ]:)y  reflex  muscular  spasm,  antl  in  part  by  an  almost 
unconscious  effort  on  the  part  of  the  patient  to  so  adapt  the  position 
and  movements  of  the  body,  as  to  insure  the  greatest  possible  protection 
to  the  spine.     Thus  attitudes  are  assumed  which  produce  a  change  in 


CLINICAL   MANIFESTATIONS    OF    BONE    AND    JOINT    TUBERCULOSIS      447 

the  habitual  appearance  of  the  patient.  There  is  an  evident  disinclina- 
tion to  walk,  with  pronounced  indications  of  physical  weakness.  The 
child  frequently  refuses  to  stand  without  support,  and  if  compelled  to 
walk,  does  so  with  slight  flexion  of  the  knees,  careful  tiptoeing  steps,  and 
with  the  arms  partly  outstretched  in  front,  as  if  in  silent  appeal  for 
immediate  support. 

Tests  to  determine  the  flexibility  of  the  spine  demonstrate,  in  addition 
to  the  stiffness,  the  peculiar  awkward  attitude  already  mentioned,  and 
changes  in  the  contour  of  the  spinal  curves.  The  abnormal  outline  and 
diminished  flexibility  are  detected  when  the  patient  is  forced  to  assume 
an  anterior  bending  po.sition.  By  means  of  this  test  a  limitation  of 
motion  of  a  particular  portion  of  the  spine  is  found  to  take  the  place  of  a 
sweeping  regular  curve.  The  ability  to  stoop  in  a  natural  way  to  pick 
something  from  the  floor  is  also  materially  diminished.  In  whatever 
method  the  cliild  imdertakes  to  seize  the  object  upon  the  floor  it  is 
noticed  that  the  spine  is  almost  invariably  held  without  flexion,  this 
attitude  being  particularly  pronounced  in  involvement  of  the  lower 
region.  In  such  cases  the  child  stands  in  an  unusually  erect  position, 
with  a  beginning  tendency  toward  lumbar  lordosis.  A  slight  unilateral 
limp  may  be  noted  as  a  result  of  psoas  contraction  from  beginning  ab- 
scess formation.  This  condition  may  be  suspected  if  unilateral  exten- 
sion of  the  thigh  is  considerably  restricted.  The  child  is  held  prone  upon 
the  table,  and  effort  made  to  raise  the  leg  with  the  pelvis  immobilized 
by  the  hand  of  the  examiner.  The  search  for  pelvic  abscess,  though 
important,  does  not  possess,  from  the  standpoint  of  early  diagnosis, 
the  significance  of  the  other  signs  already  enumerated,  as  many  months 
usually  elapse  before  its  presence  can  be  detected. 

Caries  of  the  dorsal  region  of  the  spine  is  not  especially  different  in 
many  of  its  clinical  features  from  that  of  the  lumbar  portion,  the 
described  characteristics  of  tuberculosis  of  the  lumbar  vertebrae  being 
found,  in  the  majority  of  instances,  to  obtain  with  but  slight  modifica- 
tions in  the  dorsal  portion.  In  the  event  of  involvement  of  the  upper 
dorsal  region  the  body  is  inclined  somewhat  forward,  the  head  thrown 
back,  the  shoulders  elevated,  and  the  general  attitude  that  of  marked 
debility.  A  tendency  toward  the  so-called  pigeon-breast  is  sometimes 
noted.  Slight  catarrhal  irritation  of  the  bronchial  tubes,  as  evidenced 
by  varying  degrees  of  cough,  often  coexists  in  these  cases.  The  respir- 
ation is  occasionally  of  a  grunting  character,  particularly  if  the  child  is 
fatigued.  Abscess  formation  in  the  neighborhood  of  the  diseased  verte- 
bra may  be  detected  by  the  physical  signs. 

Tuberculosis  of  the  cervical  region  is  usually  attended  by  a  peculiar 
stiffness  in  the  neck.  The  head  is  often  inclined  to  one  side,  but  may 
be  held  in  the  median  line  in  some  cases.  An  evident  disinclination  is 
noted  to  rotate  the  head  from  side  to  side.  Either  the  eyes  are  turned 
with  the  head  immobilized  in  a  fixed  position,  or  the  entire  body  is 
turned.  In  older  patients  the  chin  is  sometimes  supported  by  the 
hands. 

Without  reporting  further  diagnostic  features  inappropriate  in  this 
connection,  it  is  sufficient  to  reiterate  that  in  the  majority  of  cases  the 
warrantable  data  for  the  establishment  of  at  least  a  provisional  diagnosis 
are  ample  before  the  recognition  of  visible  deformity.  This  is  illustrated 
by  an  instructive  experience  with  an  important  case  some  ten  years  ago. 
The  child  was  between  two  and  three  years  of  age  when  the  mother 


448 


COMPLICATIONS 


noticed  a  disinclination  to  walk  or  stand,  which  she  attributed  to  general 
weakness.  After  some  weeks  the  head  became  inclined  to  one  side  and 
was  persistently  held  in  that  position.  The  shouklers  became  slightly 
elevated,  the  chin  depressed,  with  absence  of  rotation  of  the  head.  The 
awkwartlness  and  gait  of  the  child  were  characteristic.  The  knees  were 
flexed,  and  when  compelled  to  walk,  the  hands  were  invariably  out- 
stretched. The  parents  were  disinclined  to  accept  a  diagnosis  of  spinal 
caries,  and  a  fateful  period  of  delay  was  maintained  for  seven  or  eight 
months,  during  which  time  a  most  unfortunate  deformity  developed  both 
in  the  cervical  and  upper  dorsal  regions. 

In  striking  contrast  to  the  preceding,  attention  is  directed  to  a  case 
of  caries  of  the  spine  in  an  individual  with  arrested  pulmonarj-  and 
intestinal  tuberculo.sis  coexistent  with  parenchymatous  nephritis.     Fol- 


Fig.   115.— Case  of  fair. 


patient  with  advanced  puln 


vCunipare  witli  radlugrapli,  Fig.    116 


lowing  a  period  of  one  year's  complete  arrest  of  all  tuberculous  proc- 
esses, as  far  as  could  be  determined,  there  developed  a  degenerative 
change  in  both  kidneys,  followed  in  a  few  weeks  by  sudden  severe  pain 
in  the  lumbar  region,  more  intensified  upon  the  right  side  than  upon 
the  left.  There  were  marked  rigidity  of  the  spine,  slight  tenderness 
in  the  neighborhood  of  the  sacro-iliac  articulation,  inability  to  extend 
the  leg  upon  the  flexed  thigh  with  the  patient  upon  the  back,  and  other 
characteristic  evidences  of  spinal  caries.  Segregation  of  the  urine  showed 
both  kidneys  to  be  undergoing  a  parenchymatous  change,  wiih  the  proc- 
ess more  advanced  upon  the  right  side.  Repeated  pfl'orts  to  discover 
tubercle  bacilli  were  unavailing.  The  question  arose  as  to  whether  or  not 
a  tuberculous  proce.ss  in  the  right  kidney  might  |i(issili|y  cnnstitiite  tlie 
immediate  primary  cause  of  the  symptoms  refpraliie  to  the  spine  with  a 
subsequent  tuberculous  involvement  of  the  bodies  of  the  vertebra.     It 


CLINICAL    MANIFESTATIONS    OF    BONE    AND    JOINT    TUBERCULOSIS      449 

was_finally  decided  by  Drs.  Baer,  Packard,  Powers,  and  myself  that  the 
original  diasnosis  of  spinal  caries  was  correct.  There  was  no  angular 
projection,  and  the  skiagraph  shows  no  deviation  from  normal  contour 
of  the  spine. 


point  at  which  sacral 


Fig.  115  illustrates  a  pronounced  dofr 
and  lumbar  caries  and  a.  discli.'i  i-in-  im 
vation  in  Janiuuy,  l'.!()7.  Ili-  pi  linnii 
years'  standing,  following  an  aU;uk  of  a 
In  May,  1906,  after  visiting  various  health 


rnuty  in  a  patient  with  sacral 
-,  uho  i;iiiii.  under  my  obser- 
'>  ili-i':i-i'  had  been  of  four 
ipciidicitis  without  operation, 
■esorts,  he  experienced  marked 


450 


COMPLICATIONS 


pain  in  the  neighborhood  of  the  left  sacvo-iliac  articulation,  with  the  sub- 
sequent development  of  a  fluctuating  tumor  which  was  opened  at  once. 
The  lower  portion  of  the  spinal  column  is  seen  to  have  undergone  an 
abrupt  curvature  to  the  left.  The  accompanying  skiagraph  (Fig.  116) 
shows  exten.sive  necrosis  of  the  sacrum  with  moderate  involvement  of 
the  bodies  of  the  second  and  third  lumbar  vertebrae. 

The  .symptoms  of  tuberculosis  of  the  hip-joint  are  almost  always 
of  very  insidious  onset,  although  they  occasionally  begin  more  or  less 


Fig.  117. — Tuberculou.'*  infectioi 
diseased  area  is  indicated  b.v  t!ie  arr 
formation.  This  patient  died  about 
tuberculous  meningitis. 


nf  the  inferior  part  of  the  third  hniibar  vertebra.  The 
■.  Note  dark  shadow  above  arrow  resulting  from  abscess 
le  year  subsequent  to  the  time  of  this  examination    from 


abruptly.  The  condition  is  recognized  as  an  involvement  of  a  single 
joint,  thus  affording  a  differentiation  from  rheumatism  and  other  poly- 
articular affections.  There  is  no  invariable  relation  between  the  symp- 
toms referable  to  the  joint  and  the  general  condition,  although  many 
patients  are  observed  to  present  indications  of  more  or  less  physical 
debility.  Fever  is  present  in  some  instances,  but  possesses  compara- 
tively little  diagnostic  import. 

The  early  symptoms  are  pain,  lameness,  and  iniii.-iiretl  mobility  of  the 


CLINICAL    MANIFESTATIONS    OF    BONE    AND    JOINT    TUBERCULOSIS      451 


joint,  due  to  musi 
be  absent  at  Mty  si, me  nf  il 
between  the  uniouiit  cif  pai 
ing  the  joint.  It  is  soiuet 
process  involving  tlie  iiead 
the  acetabulum.  If  there 
very  intense.  <  >ften  it  is 
to  the  product  iciii  of  ni-hi 
during  the  niulit  is  iHdduii 
ation  of  the  nui.silcs,  wliicl 


spasm.     Pi 


it,  and  may 
dependence 
uige  involv- 
ilcsti-uctive 


iiiirc  pi-oiKiuiiccil  (luiiiii.;  slccj),  ;iik1  gives  rise 
(lies,  which  ha,\c  liccu  described.  The  pain 
d  by  spasiiindic  cent  lucl ions  following  relax- 
,  during  wukiiig  hours,  have  served  to  protect 
the  sensitive  joint.  The  child  does  not  always  awake,  but  if  aroused, 
rarely  complains  of  pain  or  bad  dreams,  and  does  not  exhibit  evidences 


Fig.  118. — Incipient  ttilirr 
irregularity  in  the  upper  pan  .if 
each  joint.  Clinical  symptom- 
taking  the  skiagraph,  but  were 
in  this  case  evidently  originated 
and  by  the  greater  amount  of  a 


of  fright.  In  the  early  p:i 
of  local  pain  or  sensitixci 
however,  these  syin])tiiins 
extent.  The  pain  is  usuall 
jarring  or  manipulating  th 
may  take  place.  Lameitr 
early  symptom  of  hip-joii 
less  characteristic,  the  pati 
as  pos.sible  upon  walking, 
of  gait,  with  diminution  in 
of  the  affected  joint.  The 
than  the  heel,  and  is  sjicc 
cases  there  is  a  tendencv 


'idle 
the  I 
wciuli 

'(Ul\-  1 
towai 


the  disease  there  is  but  little  admission 
1  pressure.  As  the  affection  advances, 
l)ecome  pronounced  to  a  considerable 
rred  to  the  knee,  and  is  aggravated  upon 
).  ^'a.lying  degrees  of  remis.sion  of  pain 
of  much  more  importance,  even  as  an 
•asc,  than  pain.  The  limp  is  more  or 
•in;:  cil'si  I  \ci|  to  favor  the  joint  as  much 
■c  is  a  noiiccalilc  stiffness  or  irregularity 
•iii;tii  <il  I  he  step  a,nd  a  distinct  favoring 
1  is  lioinc  \ip(iii  the  l)all  of  the  foot  rather 
raiistciiccl  to  tlio  other  foot.  In  some 
d  flexion  at  the  ankle  as  well  as  at  the 


452 


COMPLICATIONS 


knee  and  liip.  The  limp  is  more  pronounced  in  the  morning  or  after  a 
period  of  rest.  Impaired  mobility  of  the  joint  is  a  constant  feature  of 
the  disease.  The  degree  of  muscular  rigidity  is  subject  to  great  vari- 
ation, but  a  certain  limitation  of  motion  is  present  in  all  cases. 

Manipulation  of  the  joint  is  often  accompanied  bj-  pain,  especially 
when  an  effort  is  made  to  move  the  limb  to  the  full  limit  of  normal 
mobility.  Motion  of  the  joint  is  found  unrestricted  throughout  the 
range  of  a  certain  arc,  but  abrupt!}-  checked  by  muscular  resistance  be- 
yond the  limits.  The  degree  of  muscular  fixation  affords  an  approximate 
idea  of  the  progress  and  course  of  the  disease,  and  varies  directly  with 
the  sensitiveness  of  the  involved  area.  Another  result  of  the  reflex 
spasm  is  the  frequent  distorted  position  of  the  limb,  which  maj-  appear 


Fi;;.   11!!.— Iiuipient  tuberculosis  of  the  light  acetabulum.     The  head  of  tl: 
markedly  upward  and  outward  as  a  result  of  muscle  contraction.     Contrast  tl 
head  of  the  right  femur  in  the  acetabulum  with  that  of  the  left, 
the  right  femur. 


[eniur  is  drawn 

position  of  the 

ote  characteristic  atrophy  of 


to  be  either  lengthened  or  shortened.  The  apparent  lengthening  is 
])roduced  by  abduction  and  outward  rotation.  This  attitude  is  fre- 
quently assumed  in  early  cases  upon  standing,  and  is  attended  b}'  a 
tlownward  and  forward  tilting  of  the  pelvis. 

An  instinctive  effort  is  made  to  insure  protection  :ind  support  to 
the  affected  joint  by  resting  the  lower  part  of  the  le.i;:  of  the  affected 
side  upon  the  foot  of  the  sound  limb,  so  guarding  its  movements  as  to 
avoid  shock  or  jar.  Upon  walking,  the  direct  impact  of  the  femur  upon 
the  acetabulum  is  lessened  by  the  spring-like  action  of  the  flexed  ankle-, 
knee-,  and  hip-joints. 

The  characteristic  position  of  the  limb  represents  an  unconscious 
effort  to  diminish  as  much  as  possible  the  function  of  the  joint  in  support- 
ing the  weight  of  the  superincumbent  body.     The  appearance  of  length- 


CLINICAL    MANIFESTATIONS    OF    BONE    AND    JOINT   TUBERCULOSIS      453 

ening  of  the  iiffcctcd  lunl),  for  which  compensation  is  afforded  by  tilting 
of  the  ])cl\is,  \:iiics  with  the  degree  of  abduction,  which  is  usually  asso- 
ciatetl  with  (uilward  icilaUiin. 

An  appeal':,!!.,.  . ,!  >!„ „! .-iiini;  is  proihiccl  by  flexiiin  and  abihiction 
with  in\\a,!'d  !'(ilaa!(ii!,  \\]\\i\\  pn-ilioi!  \n  iikhv  a,.l\a,!!i\,[  c-ascs  is  \-(iliinta- 
rily  assiinicil  upon  walkiuu.  This  is  ai-i'iil!!pa!i!,'(l  b\-  ai!  iipwai-d  tilting 
of  the  affected  side.  When  the  lii!ib  is  apipajcni  l\-  l.n-thcnetl,  the 
fold  between  the  thigh  and  -hitcal  lat  i-^  l.-wci^  than  ii<  Idlow  of  the 
opposite  side,  and  is  less  piduniinccd  mi  a<-c(i!int  ni  ihc  llcxion  of  the 
thigh,  ^^■hpn  the  limb  presents  the  appearance  of  shortening,  the  glu- 
teal foil!  is  higher  and  shallower  than  upon  the  unaffected  side,  while 


Fig.  12U.— I  uli.i.  uh.ii-  in!,.,  lion  of  tlie  left  acetabulum,  llie  Ui^east-  ih  uiduau-a  in  tlie 
skiagrapti  by  ttie  Imliin  -li:i,|,r.\  -  wljicli  are  seen  in  the  upper  part  of  tlie  acetabulum.  Note  the 
atrophy  that  has  laki  n  |.|:ii  i  in  lii.-  left  femur.  This  skiagraph  shows  the  disease  a  little  farther 
advanced  than  in  npu-cnir.l  m   lUrs.   118  and  119. 

in  front  the  vulva  is  elevated  and  the  inguinal  fold  is  deepened  and 
lengthened. 

Atrophic  changes  in  tlio  muscles  of  the  affected  limb  are  almost 
constant,  and  aic  espei  iall\-  pii nn niiiced  in  the  thigh  and  gluteal  region. 
Theatn.phy  takes  place  siirpriMiidv  early. 

Sui>i)uration  ma\-  (lenir  liotli  wiiliin  :iiid  without  the  joint,  and  give 
rise  to  external  exideme-  nl  ali~ie--  lurmalicm,  pus  often  presenting 
in  the  anterior  and  latei'al  ivLjimi-  <>l'  ilie  thi'^ih. 

Late  in  the  course  ol  liip-jdini  ili-ea~e  actual  shortening  of  the  limb 
may  take  place.  This  (•iiiiditiiui.  l!(i\\('\ cr,  is  of  loiiipaiatixcly  .slight 
importance  in  diagim-i^  on   .■indunt    nl    its  delaM'd   iiLaiiifestation. 

In  Figs,  lis  to  124  inclnsixe  are  shown  the  .serial  stages  of  hip- 
joint  disease  from  incipiency  to  recovery  as  disclosed  by  the  .r-ray. 


454 


:'OMPLICATII)NS 


TIio  t 
the  van. 
hip-(li>ca 
Strict h'  \\ 

TllC    s 

essential 


lesions   mentioned  on  p.  -145.     Atteiiti 


lyrical   cxaiiiiiiatinn.   the   inctlKMls  of  ascertaining 

MHv  tliaii  any  uiIut  till  icriailmis  joint  lc>ion,  belong 
nam  oforthopeilic  sur!j,ei-\-. 

tuberculosis  of  the  knee-joint  cont'onn  in  their 
the  siciu'i-al  (lesciiptiou  of  tuliercrJous  joint 


diiecteil  to  local  swell- 


s/6 c£^\i.  ^ 


Fig.  121 
almost  en 
pus  from 


%.  121. — Active  tuberculous  disease  of  i 
entirely  absorbed.  A  drainage  tube  is 
m  the  joint  daily  at  tlie  time  of  tiie  ex 


i  left  liip-joint. 


ing,  tenderness,  pain,  circumscribed  temperature  elevations,  infiltra- 
tion of  tissues,  limitation  of  motion  and  flexion.  The.se  changes  afford 
a  fairly  accurate  characterization  of  the  symptoms  of  knee-joint 
tuberculoisis.  Lameness  is  usually  present,  the  limp  varying  with  the 
intensity  of  the  inflammatory  and  destructive  proce.ss.  The  swelling 
is  produced  by  the  pathologic  changes  in  the  neighborhood  of  the  joint, 
in  the  synovial  membrane  it-self,  and  by  the  presence  of  moderate  effusion 
between  the  articular  surfaces.     Motion  is  limited,  and  flexion  is  invari- 


CLINICAL   MANIFESTATIONS    OF    BONE    AND    JOINT    TUBERCULOSIS      455 


Fig.  122.— Well-marked  tulx 
femur.  The  disease  in  this  case  1 
is  becoming  established.     Note  tl 


iphy  oi"  tlie  left  femu 


Fig.  123.- 
use  of  the  leg.  i 
been  absorbed 
are  well  shown 


456 


COMPLICATIONS 


ably  present,  as  well  as  reflex  spasm  of  the  muscles.  The  degree  of 
flexion  corresponds  largely  to  the  acuteness  of  the  infection.  Other 
deformities  of  a  secondary  character  may  take  place.     The  various 


femur  has  been  absorbed.     Firni  boii 
acetabulum,  permitting  no  moveraen 


displacements  of  the  tibia  upon  the  femur  with  certain  other  deformities 
are  late  manifestations  of  the  condition,  and  do  not  require  more  than 
mention  of  their  occasional  existence  in  such  cases. 


TREATMENT    OF    TUBERCULOSIS    OF    BONES    AND    JOINTS  457 

CHAPTKPv    LXV 
TREATMENT  OF  TUBERCULOSIS  OF  BONES  AND  JOINTS 

It  is  possible  to  consider  but  briefly  the  principles  upon  which  is 
based  the  management  of  tubei'culdus  bones  and  joints.  Obviously, 
no  attempt  can  be  made  to  dis(•ll^s  .^iiccial  methods  of  treatment,  par- 
ticular mechanical  coiit  ii\  .nirc,-.  m  dtho'  icclniical  features. 

The  treatment  musists,  lirsi,  i>i  f;encial  liy.uicnic  ni:mai;omont ,  and, 
secondly,  local  nicasiuvs,  which  may  be  non-opera.ti\c  or  |imcl\  >iii-ical. 

General  Hygienic  Management. — The  hy;;iciiic  tivai  incnt  of 
tuberculosis  of  Ixmcs  ;uul  joints  is  i<lentical  willi  that  of  tuberculosis 
of  the  I\iiiiihalii'  lilauils,  to  which  attention  has  been  (hrected.  It  is 
important  to  cniiihasize  a.iiain  the  incstiinaMc  \ahic  of  an  out-of-door 
existeiu'c,  comliiniMi  with  a  suitalilc  (■n\iionnicnt  at  tiie  seashore,  the 
country,  or  the  nioiini  ains.  ii  is  possililc  tlia,t  the  wonderful  advan- 
tages ai'cniniLi:  innii  the  appHcation  ol'  thoc  ]iiinc-i]ilcs  of  treatment 
are  more   coir~|iiiaions   in    I'oiic   and    jonit    tnbcrciiloMs    tliaii    in    cases 

surgeoir-  ID  the  bciidit^  rc-rliMiL!  iioiii  nn|ii-o\c(|  nutrition  and  in- 
creased unUvidual  resistance.  1;\  tin  mean,,  direct  surgical  inter- 
ference is  often  avoided  eniirel>-.  whcieas  in  other  cases  such  inter- 
vention is  permitted  to  take  place  at  a  time  when  the  general 
vitalitv  and  condition  of  the  lis-nes  i[\v  such  as  to  insure  not  onlv 
a  more  rapid  he.alin,-.  but  t,,  le,-.,.n  inat.a'i.aljy  the  Hk.'Hliood  ,;f 
further  tilbeivulon-  dis>enunatioiu  bi  tlie  excnt  ol'  lno,|ei-ate  lil.rous 
tissue  pruliferalioii  aliout  a  tubercujcjiis  focus,  operatixc  sui'i:(  ly  is 
attended  with  much  less  danger  of  geneial  tubeiculou-  iniection  than 
when  fresh  open  surfaces  are  brouglit  directly  in  contact  with  in- 
fective material.  The  process  of  repair  in  su(  li  ca-i  -  i'oii-i-t<  essen- 
tially of  the  indosure  or  incapsulation  of  the  i  uliei  ( nloi,:-  locu-  ky  a 
barrier  of  protective  connective  tissue.  Absoiption,  a-  well  a-  elimiiui- 
tion  through  abscess  formation,  at  tinie<  \']:i\>  an  iiupoitaiit  pait  in 
an  arrest  of  the  Ji^ea.se,  but  the  foi  iicil  ion  ot  uraiiulal  ion  ti-sm-  m  the 
l)eii])hery  (p|"  tlie  diseu.sed  area,  and  n-  >ul>~e'iueni  oi '^auu'ai  on  icsulling 
in  den.se  fibrous  tissue  development  con-thutes  natin-e':-  const  met  i\-e 
efforts  toward  the  aiav-t  of  the  tuberculous  h^-i-m.  It  must  Ik-  remem- 
bered that  tlie  condition  is  liihnriilosis  presenting  the  same  features 
of  pathologv  as  the  pulnioiiaiw  affection, 
difteren.vs  in  tvpe,  but,  neveVt  helc-s,  si 
and  ahordin- similar  indications  in  the  w: 
The  reparative  pr.ic.-ses  ,-,!e  accelerated 
inci-eased  gener.-il    \-il;ilii\-   :]iid  tlu'  local 

essential    consideration,    therefore,    in    all 

fortify  the  .general  condition  by  a  conscii 
application  of  the  principles  of  nutrition  : 
air,  with  an  abundance  of  nutritious  food  : 
increases  the  reparative  forces  to  an  e> 
therapeutic  agent. 

In  those  cases  in  which  the  articular  surface  of  the  joint  is  not 
seriously  involved,  although  an  intact  cartilage  may  be  found  to  con- 
ceal  an  extensive  destructive   process  in   the   bone,   general   hygienic 


.xllilulillL!.    It    i 

<.,  dn 

linct 

ject     to    111,'    s; 

;i  nie 

,ples. 

',  '!'■' 

liagi'l 
ion   t( 

iient. 

.  the 

sistalice  of  tli 

e  tis> 

lies. 

The 

ises    is   the    ]il 

iniar 

V  etto 

It  to 

ions  and    s,)!) 

letlll 

dii'al 

d  hv-iene,       1 

.ife  11 

a  the 

open 

1  opportunit\ 

'  loi'  1 

■eciea 

tion, 

■ut   unequalet 

1  by 

any  1 

jther 

458  COMPLICATIONS 

management  alone  is  sometimes  sufficient  to  briii;:  altont  an  ultimate 
quiescence,  if  not  arrest,  of  the  tuberculous  pi i »(•-■.  I!\(ii  in  cases 
in  which  the  joint  is  involved  to  such  an  extent  as  \n  pircliulc  the  control 
of  the  disease  and  to  necessitate  active  sur.iiical  intcixcntion  there 
may  be  afforded,  through  a  period  of  rest  in  the  open  :iii-,  with  enforced 
nutrition,  a  heightened  soil  resistance  and  a  suitaMr  prciiaiaiion  for  the 
surgical  ordeal.  The  importance  of  the  constilutiunal  treatment, 
therefore,  can  scarcely  be  exaggerated,  and  equals  in  many  instances 
the  efficiency  of  all  local  measures  of  treatment,  including  the  various 
forms  of  apparatus. 

The  value  of  the  general  regime,  aside  from  the  immediate  en- 
vironment and  other  features  of  management,  is  dependent  upon  the 
amoimt  of  sunshine  and  the  number  of  hours  in  the  day  that  the 
patient  is  in'iniiitcil  to  remain  in  the  open  air.  As  stated  in  connec- 
tion with  the  h\  wienie  treatment  of  glandular  tuberculo.sis,  there  is  a 
conflict  of  opinion  in  regard  to  the  relative  ad^•:lntaL'os  of  the  sea,  coun- 
try, or  mountain  air.  It  is  apparent  tlnit  ihi'  -ci-ioa-i  sanatoria  upon 
the  shores  of  the  Mediterranean  or  the  .-Vdnatir  aiv  haiilly  siiital.)le  for 
comparison  at  all  times  of  the  yeai-  with  re.-oii,-  ii]mjii  ilie  Ailantic  coast, 
on  account  nf  dilTeriiiL:  \\i\-ithei'  con  .lit  ions.  If  the  uodd  elTecis  in  various 
locations  are  pidiluced  to  aii\-  extent  1  >y  the  aindiint  (d'  sunsliine  and 
other  I'liinaiic  cuiiilitiuiis  artnr(liii<i-  un  outdoor  existence,  it  is  reason- 
able ti)  UelieNc  iliai  I  lie  \'eiy  best  results  Can  be  obtained  in  those 
regions  |ieriiiiniii;^  the  iiiii-t  eiiinplete  elaboration  of  the  principles 
upon  which  depend  the  elHriency  of  the  treatment.  Judged  by  this 
token  alone,  the  climate  of  the  eastern  Rocky  Mountain  slope  offers 
opportunities  for  improvement  from  bone  and  joint  tuberculosis  un- 
surpassed in  any  othei-  sertimi  of  the  country.  The  every-day  ex- 
perience of  clinicians  m  ('n|,iiai Id  affords  convincing  proof  of  the  truth 
of  this  assertion.  The  i  ..n-in-u.;  of  opinion  among  general  and  ortho- 
pedic surgeons,  as  well  a-  luiei  nists,  is  to  the  effect  that,  in  spite  of  the 
peculiar  hereditai>-  pictli~|iii  itiou  on  the  part  of  a  large  portion  of  our 
infant  populatinu.  tulx  iculuus  hdiie  and  joint  lesions  are  remarkably 
rare.  There  is,  Ijeyonil  i|iH-ti(iii.  dpcidedly  less  tendency  toward  sup- 
puration and  active  syiii|iidiii~  iliaii  is  ic]idit  •.[  td  evi^t  in  other  regions. 
Actual  experience  lias  denidiist rated  a  -hditer  duratidii  of  the  disease  in 
Colorado  and,  as  a  rule,  tlie  attainiiieiit  of  better  functional  results. 
The  details  of  an  open-air  regime,  either  within  or  without  sanatoria, 
will  1)6  reserved  for  the  Treatment  of  Pulmonary  Tuberculosis. 

General  medicinal  measures  are  of  but  slight  avail,  though  tonics 
and  nutrients  are  sometimes  indicated  by  an  anemic,  im])overished  con- 
dition. The  administration  of  the  bacilli  emulsion  of  Koch  is  now 
recognized  to  be  of  undoubted  value  for  many  of  the.se  cases,  and 
promises  to  constitute  one  of  the  exceedingly  important  features  of 
treatment. 

The  local  management  of  tuberculous  joint  lesions  includes  non- 
operati\c  iiirasiitvs  and  active  surgical  intervention.  The  choice 
between  iIk-c  two  lieneral  methods  of  procedure  depends  upon  essential 
diffei-eiire-  ill  till'  I  xjie  of  the  disease,  its  acuteness,  the  extent  of  destruc- 
ti\'e  cliaiiue,  Idcatidii.  inipairnieiii  df  i'linctidii.  pi'esence  of  suppuration, 
especiallx-  if  a-~d(ialed  willi  ^ecdihlaiy  iiilertion,  the  danger  to  life, 
existence  of  tiiberculous  foci  iu  other  parts  of  the  body,  and  the  age  of 
the  patient.     The  decision  should  rest  not  solely  upon  the  consideration 


TREATMENT    OF    TUBERCULOSIS    OF    BONES    AND    JOINTS  459 

of  a  single  factor,  but  i-ather  iijion  a  review  of  all  the  clinical  features. 
It  is  essential  that  a  wcll-sustaiiKMl  estimate  he  made  uf  their  l)earing 
upon  the  life  of  the  iinlividual  and  the  preservation  of  function.  It  is 
clearly  the  duty  of  the  surjicon  to  lie  i>rcpared  to  eniijluy  all  rational  mea- 
sures with  a  wise  discrimmat  ion  aicoiding  to  widely  varying  concUtions, 
to  the  end  that  life  may  be  sa\cd  «  iihdut  unnecessary  mutilation.  Treat- 
ment along  the  lines  of  <'onsci\ai  i\r  siii-,i;cry  iia.^  been  jiroductive  of  liiglily 
gratifying  results,  save  in  those  instanrcsdcnia,ndi  iiL::iinnici  li, -it  c  opci^a-tive 
interference  upon  the  basis  of  cci'lain  I'linical  or  pal  liolo^ic  daia..  In 
the  latter  event  meclianical  contrivances  arc  as  nnich  out  of  phicc  as 
amputation  would  be  in  favorable  cases.  When  the  exigency  exists, 
however,  there  should  be  no  hesitation  even  in  sacrificing  a  liml)  in 
order  to  preserve  life. 

In  general,  it  may  be  stated  that  in  children  with  tuberculous 
bones  and  joints  the  field  of  operative  surgery  is  comparatively 
limited.  At  this  age  the  lymphatic  sj^aces  are  more  permeable 
and  thcic  is  neater  danger  of  (li-,-(inination  of  the  disease.  This 
is  partirulaily  true  if  operations  aic  pcrloi mcd  before  opportunity  is 
affordc.l  ior  abundant  fibrous  tissue  loiniaiioii  about  a  tuberculous  area. 
Fibrosis  lakes  place  luucli  nioi-e  .|Uiekl>'  aiuou-  childi-eii  than  adults, 
onaccouni  of  ilie  rapidly  ioi'nun-  i;i'anulat  imi  li-sue  in  eaiix'  Hfe.  Thus 
the  process  of  repair  is  often  siiHieieiil  in  I  lie  \'er\  \(iunii  to  insure  such 
a  degree  of  arrest  of  tlie  tubeicuious  picjcess  as  would  be  iiii|iossible  in 
later  life.  At  the  same  time,  afler  urowtli  lias  been  atlained.  exrision 
of  a  tuberculous  area  does  not  in\ol\'e  the  loss  of  as  w'ulc  a  portion  of 
healthy  bone  as  is  ti-iie  in  the  lirowing  tissues  of  cliildicn. 

Nichols  has  shown  that  there  is  an  undoiibled  tuberculous  infection  of 
bone,  at  least  an  inrh  beNond  the  limits  of  its  macroscopic  a]ipparance, 
thus  suggestim:  the  expediency  of  renio\iim  a  considerable  |ioition  of  ap- 
parently unaffectei  1  lioiii'  \\lieiie\-ere\c|sion  is  practised.  Such  a  procccl- 
ure,unfortunatel\  ,  lii\(>l\csa  sile  of  operation  outside  the  |iroleiti\e  barri- 
ers of  fibrous  tissue  formal  ion,  ■iiiddoesa\va\-at  on, -e  with  t  he  ad  vantages 
derived  from  this  source,  to  winch  allusion  has  been  made.  .\,uain,  it  is 
questionable  if  it  is  always  ad\isab|e  to  atiempi  the  .•oniplete  lemoval 
of  infected  tissues.  As  a  matter  of  lad,  \\u'  operation  is  often  more  or 
less  incomplete  at  best,  thou.-h  atien.led  by  excellent  I'esults,  thus  sug- 
gesting the  important  i-61e  of  the  n.-itur.il  repa,rati\e  forces.  Therefore, 
operations  upon  children,  in  whom  the  lou-t  luctiNc  ilToit-  toward  arrest 
are  most  pronounced,  are  to  be  aMnded  on  a<coiini  oi  ihc  unnecessary 
sacrifice  of  healthy  bone  and  the  .unater  likelihood  ol  further  extension 
of  the  process.     In  this  conn<'ctioii  it  is  well  to  call  attention  to  the  fact 

that  in  nearly  all  cases  the  i>one  lesion  is  sec lai\   to  other  foci  in  the 

lymphatic  glands.     The  removal  of  the  sec lary  focus  is  not  followed 

by  a  complete  restoration  of  health  unless  tiie  surgical  treatment  is 
accompanied  by  so  complete  an  elaboration  of  the  principles  of  hy,i!:ieinc 
management  as  to  insure  the  incapsiilation  of  the  primary  seat  of  dis- 
ease. In  adults  the  primary  focus  is  more  likely  to  be  quiescent,  if  not 
entirely  arrested,  and  the  extirpation,  therefore,  of  the  local  secondary 
lesion,  even  of  long  standing,  is  less  apt  to  he  followed  by  renewed 
infection  than  in  early  life.  Conservative  measures,  then,  are  to  be 
employed  in  children  whenever  not  positively  contraindicated. 

Local  non-operative  procedures  consist  of  the  application  of  such 
varying  forms  of  apparatus  as  will  enforce  rest  and  secure    a    degree 


460  COMPLICATIONS 

of  fixation  and  extension.  As  far  as  the  local  treatment  is  con- 
cerned, these  three  conditions  constitute  the  essential  desiderata  in  an 
effort  to  arrest  the  tuberculous  process.  Thus  protection  is  also  afforded 
against  further  injury,  and  suppuration  rendered  less  likely.  The  ulti- 
mate preservation  of  the  function  of  the  joint  is  rendered  more  probable 
as  the  local  irritation  diminishes.  Fixation  of  the  joint,  with  complete 
rest  and  traction,  not  only  lessens  the  joint  pressure,  but  relieves  pain 
and  muscular  spasm. 

Goldthwait  chffers  from  the  majority  of  orthopedic  surgeons 
in  believing  that  the  joint  should  not  be  absolutely  confined.  He 
favors  merely  a  limitation  of  function  rather  than  complete  fixa- 
tion. He  limits  the  motion  of  the  joint  only  to  such  an  extent  as 
will  control  the  symptoms,  and  permits  the  use  of  the  joint  up  to  the 
point  of  toleration,  believing  that  by  this  means  there  results  less  dis- 
turbance of  the  circulation  and  nutrition.  In  other  words,  he  regards 
the  principles  of  treatment  of  tuberculous  joint  lesions  as  closely  analo- 
gous to,  if  not  identical  with,  those  involved  in  the  management  of  pul- 
monary tuberculosis.  He  takes  the  position  that  the  respiratory  func- 
tion in  the  latter  cases  should  be  in  no  way  restricted,  and  in  order  still 
further  to  increase  respiratory  effort,  he  advocates  considerable  activity 
in  high  altitudes,  combined  with  special  exercises  along  the  lines  of 
pulmonary  gymnastics.  His  conclusion  as  to  the  wisdom  of  retaining 
a  limited  function  of  affected  joints  is  entitled  to  an  appreciative  con- 
sideration, for  his  views  are  based  upon  an  experience  sufficient  to  carry 
conviction  as  to  the  accuracy  of  his  opinion.  The  principles  of  treat- 
ment of  the  pulmonary  involvement,  however,  as  regards  exercise,  should 
not  he  accepted  as  belonging  to  the  same  category  with  those  apjilicalile 
to  affected  joints.  In  one  case  the  condition  is  purely  local,  not  tlirectly 
involving  the  preservation  of  life,  and  subject  almost  entirely  to  mechan- 
ical principles.  In  the  other,  the  \atal  organs  affected  are  constantly 
performing  the  function  necessary  for  the  continuance  of  life. 

Nearly  all  orthopedic  surgeons  agree  that  after  the  acute  stage  has 
been  passed,  with  extension  in  the  recumbent  po.sition.  limited  motion 
may  be  cautiously  permitted,  pro^ided  the  diseased  joint  is  jjrotected 
from  bearing  the  weight  of  the  l)ody.  It  is  manifestly  impossilile  to 
discuss  the  relative  merits  of  the  various  methods  of  securing  rest,  fi.\- 
ation,  and  extension  for  the  tuberculous  joint,  or  to  enter  into  a  con- 
sideration of  the  numerous  special  appliances,  all  of  which  aim  to  afford 
as  much  protection  as  possible  to  the  joint.  The  purely  technical  con- 
sideration of  mcclianical  contrivances  is  strictly  within  the  pro\ance  of 
the  ortlni]>('ilii-  -uriieon. 

In  (iiiiiraili-tiiiction  to  the  employment  of  apparatus  whose  action 
is  confined  as  far  as  possible  to  the  restriction  of  motion,  utilization 
is  sometimes  made  of  passive  congestion  without  confinement  of  the 
joint.  The  so-called  Bier  treatment  of  t^iberculoii^  joints  consists  of  the 
establishment,  through  mechanical  means,  of  a  localized  passive  con- 
gestion. The  venous  circulation  is  constricted  by  means  of  a  rubber 
bandage  above  the  affected  joint,  applied  in  such  a  manner  as  not  to 
interfere  with  the  arterial  supply.  In  order  to  localize  the  congestion 
the  limb  is  bandaged  from  its  distal  portion  nearly  to  the  lower  part 
ol  the  tuberculous  joint.  The  principle  of  treatment  is  based  upon  the 
clinical  fact  that  pulmonary  tuberculosis  is  seldom  observed  in  people 
suffering  from  passive  congestion  of  the  huigs  incident  to  cardiac  di.s- 


TREATMENT    OF    TUBERCULOSIS    OF    BONES    AND    JOINTS  461 

turbance.  The  vonous  coniiostion  is  believed  to  increase  phagocytosis, 
stimulate  absDipiidn.  dimiiiish  the  activity  of  the  disease,  and  acceler- 
ate the  fonnatiiiii  nl'  IiImous  ussuc.  Relief  of  pain  and  other  beneficial 
results  occasionally  attend  the  employment  of  this  method.  It  would 
seem  that,  if  it  be  used  at  ail  in  the  treatment  of  joint  tuberculosis,  it 
should  not  be  permitted  to  suj^plant  entirely  the  protection  afforded  by 
rest  and  fixation  of  the  juint. 

The  piiicly  siii-ijinil  procedures  consist  of  amputation,  excision  of 

joint,   eia-iiiii   111    I •,   and  the  management  of  tuberculous  abscess. 

Amputalion  is  iiccaMiiiKilly  demanded  in  adults  on  account  of  complete 
orextensi\T(lcsli'Ucli(iii  (if  lioiir  and  a,  ^i-cath-  iiiipaii-eil  i;riici'al  resistance. 
The  sacniir,.  uf  the  liiiil,  is  .-penally  indi.'al.'d  if.  in  s].ilc  .,f  tlic  bc-t  of 
food  and  surroundings,  the  general  condition  is  shown  to  grow  progies- 
sively  worse. 

Excision  of  the  joint,  which  consists  of  the  complete  removal  of  the 
articular  surface  of  the  diseased  bones,  is  not  uncommonly  practised 
in  adults  and  si)nictiriii-s  in  childivn.  Tlic  iiHli<'ati(.n  for  tlic  (i]icration 
is  the  known  exlcai-ixc  dcsl  met  imi  of  the  art  iiaihit  ilii:  surfaces,  i-ciider- 
ing  the  joint  iiiualy  hopeless  and  jire.senting,  at  the  same  time,  a 
constant  nienarc  to  tho  patient  on  account  of  the  possibility  of  further 
tuberculous  (hssciiiiii.at  ion, 

Erasion  or  the  renu.ival  of  a  localized  area  of  bone  is  sometimes 
possible  without  resorting  to  complete  excision.  It  (iniM-ts  ol  tlie 
extirpation  of  diseased  l>one  tissue  by  means  of  knife,  gouuc.  cuni,  cir 
scissors,  followed  by  the  free  use  of  iodin,  pure  phenol,  or  alcohol,  in 
order  to  avoid  the  danger  of  secondary  infections  or  extension  of  the 
tuberculous  disease. 

The  treatment  of  tul)erculous  aliscesses  should  vary  to  some  extent 
according  to  the  e^■i(l(■U(•(■s  of  general  infection  and  the  inijiaii'nieiit  of 
function.  In  case  of  cousiileraMe  teni|ieratui-e  elex'atioii,  with  or  with- 
out chilling,  togethei-  with  a  delerioiation  in  the  geiii'ral  coiidilion, 
incision  and  dl'aill:iuc  should  be  perh.iaiied  willi  as  tlioroU',:li  disiiileel  ion 

of   the   cavity    as    possilile.       if.    I.,,wever,    the    pivseiie '    the    al.-eess 

occasions  niei'ely  an  iniei'fereiice  of  lniicti( 
temic  infection,  elf'oHs  towaid  the  reiiio\al  n'  : 
tion  are  to  be  enip|o>-ed  bejoic  resoriing  to  1 
tion  is  prefer.aMe  in  sncli  e;i<es  ,,n  ;ieionnt  of  I 
of  extension  of  llie  dl-e:,-e,  the  ,-i\oidance  o 
of  general  se|ilicenn:i  lliroiiL;li  coiil  .a  iiiin:it  i<iii 
The  question  ol  ml  ern^ivn.-e  uilli  elo-ed  IuIh 
or  joint  orimii,  without  se,-ond;ir\-  iiifeclioii  ( 
remains    ni.ire   or   less  ..»/,  jinlw,.      (  ei'tain    it    i-   !l,;il    m    inanv    ca-e-   the 

sibility  of  resulting  sinuses,  and  the  secondary  infection  afford  strong 
arguments  against  precipitate  surgical  interference. 


.ilhout    a    ,i:ener;il 

sys- 

I'mm,   mla'i!.:'."  .\s 

inra- 

■olid,ar\-    ildection 

iiigcr 
and 

ni  a  di-vliariiings 

mus. 

I.His   al.-re^~,.s,.f 

bone 

COMPLICATIONS 


SECTION   VI 
Tuberculosis  of  the  Alimentary  Tract 


CHAPTER   LXVI 
ETIOLOGIC  AND  ANATOMIC  FACTORS 

Tubercle  deposit  may  take  place  throu.diout  the  entire  course  of 
the  digestive  canal  from  the  lips  to  the  anus,  although  a  very  consider- 
able difference  is  noted  in  the  vaiious  parts  as  to  the  frequency  of  involve- 
ment. Inasmvich  as  the  relative  merits  of  the  respiratory  and  digestive 
systems  in  offering  a  port  of  entry  to  the  bacillus  have  been  reviewed 
in  detail,  it  is  unnecessarj^  at  this  time,  to  discuss  the  alimentary  canal 
as  a  channel  of  initiol  tuberculous  infection.  Attention  is  directed 
solel}^  to  the  various  sites  of  tubercle  deposit  along  the  via  naturales,  in 
connection  with  diverse  etiologic  factors  of  an  anatomic  or  physiologic 
nature. 

Tuberculous  lesio7is  of  the  biiccal  mucous  metnbrane  are  exceedingly 
infrequent.  In  view  of  the  passage  of  bacilli-laden  sputum  through 
the  mouth  of  consumptives  in  the  act  of  expectorating,  it  is  apparent 
that,  in  addition  to  certain  anatomic  conditions  producing  a  relative 
invulnerability  of  tissues,  there  must  be  present  other  con.siderations 
of  a  physiologic,  chemic,  and  mechanic  nature,  in  explanation  of  the 
rarity  of  local  infection.  The  squamous  epithelium  of  the  buccal 
mucosa,  in  the  absence  of  injury,  is  almost  impermeable  h}-  the  bacilli, 
in  marked  contrast  to  the  columnar  epithelium  of  the  small  intestine. 
Cornet  has  called  attention  to  the  thickening  of  the  mucous  membrane 
of  the  mouth  In-  the  continual  mechanic  friction  induced  by  mastication. 

It  has  been  asserted  by  some  observers  that  the  infrequeney  of  oral 
tuberculosis  is  due  to  the  fact  that  infective  material  is  seldom  retained 
within  the  mouth,  either  being  swallowed  or  expectorated  without  delay. 
This  explanation  would  seem  to  be  quite  insufficient  in  view  of  the 
facilities  for  retention  of  microorganisms  in  the  numerous  recesses  of  the 
mouth.  Bacilli  have  been  found  in  decayed  teeth,  and  there  is  no  reason 
why  they  may  not  be  present  in  the  fold  Ijetween  the  cheek  and  the  gums. 
The  removal  of  a  carious  tooth  in  a  consumptive  is  occasionally  followed 
in  the  course  of  some  months  by  necrosis  of  the  lower  jaw.  suggesting 
the  possibility  of  an  extension  of  the  infection  through  the  open  extrac- 
tion wound. 

The  mouth  is  known  to  contain  a  most  luxuriant  bacterial  flora, 
representing  many  varieties  of  microorganisms.  While  the  mouth 
and  entire  digestive  tract  of  an  infant  at  birth  are  absolutely  sterile, 
there  shortly  appear  in  the  stools  colon  bacilli,  yeast-cells,  and  the 
bacillus  lactis  aerogenes.  The  belief  in  some  quarters  that  the  presence 
of  these  germs  was  even  essential  to  life  has  been  disproved  by  the 
experiments  of  Xuttall,  who  found  guinea-pigs  to  thrive  after  the  estab- 
lishment and  maintenance  of  a  perfectly  sterile  condition  of  the  alimen- 
tary canal  for  a  considerable  period.  The  mouth  is,  indeed,  the  habitat 
of  innumerable  germs  of  varying  description,  whose  place  of  abode  is 


ETIOLOGIC    Ai\D    ANATOMIC    FACTORS  463 

not  necessarily  confined  to  concealed  recesses.  It  is  likely  that  the 
action  of  these  microorganisms  upon  the  secretions  within  the  month 
is  such  as  to  exert  an  inhibitive  effect  upon  the  development  of  the 
bacilli.  It  is  not  clear  whether  the  influence  opposed  to  local  bacillary 
infection  relates  to  the  conversion  of  the  normal  alkaline  saliva  into  an 
acid  secretion  by  the  presence  of  the  various  germs,  or  to  the  action  of 
certain  bactericidal  properties  of  the  mucus.  With  an  unbroken  con- 
tinuity of  the  mucous  iiiciiil)i;iiic'  I(m:i1  infection  is  extremely  infrequent, 
but  the  rarity  of  buccnl  t  ii1iciimiI(]ms  niuy  hardly  be  explained  by  a  sup- 
posed absence  of  the  uilci-ii\c  uncut. 

The  site  of  nearly  all  t  ulinrulcius  Ii-kuis  within  the  mouth  is  found  in 
excoriations  of  the  nincdsa  lullowin^  ]iic\iiuis  injury  or  disease.  Local 
mechanic  irritation  of  the  tdii^iic  uriMiiu  IVcuii  a  sharp  projecting  tooth 
has  been  known  to  afford  a  jodiiinii-placc  for  lubi'iclc  bacilli  .iiiiong 
advanced  consunipti\cs.  li  has  not  been  sli(j\\n,  1io\\(.>\(t.  that  s\ich 
irritants  as  alcohol  and  tobarco  have  an  c.^pcciul  predi.sposing  inlhieuce 
upon  the  development  of  tlir  local  idinliiion. 

The  to?igweislessfnM|Ufntly  imoUcd  upon  its  upper  or  lower  surfaces, 
the  tip  and  lateral  niafiiins  bcini:  t  lie  most  com  moii  seat  of  the  tulicrcio  de- 
posit. The  process  is  usually,  p  iti^  supeificial.  cnnsi.t  in- of  inlilt  r.ation  or 
shallow  ulceratic  a  IS.  'I'lie  outlnie.  as  a  fule.  i,-  irivuul.ai'.  and  the  eilges 
are  sli?htlv  beveled.  Small  v.'llo\\ish-i:Tav  spots  nia\-  be  discei'iie.  I  here 
and  there'upol.  t  he  iv.ldisl, .  -r.auulat  m- sui'lac.  Tlieiv  is  but  litllesin'- 
roundiim-  induration,  altliouuli  .aitei'  c.uii|ileie  lacal  I'iz.at  icai  this  is  some- 
times noted.  The  pinii  and  oilier  sul.jecti\c  ,s\inptoins  are,  as  a  rule, 
comparativelv  sli^lit,  in  contradistinction  to  llie  ilisc.jmlori  and  suffer- 
ing e-xperience.l  in  the  event  of  t  ubiaviilous  imol  \ vnieiit  of  the  soft 
palate,  ton  als.and  ]iliaiyii.\.  Seldom  is  there  found  a  secondary  enlarge- 
ment of  the  i'er\ical  ulalids. 

Tuhi  iriil(isi.-<  <>/  tin  ijiniis  conforms  in  general  to  the  type  of  lesions 
found  upon  the  tmimie  and  hard  j^alale.  the  infection  being,  as  a  rule, 
relatively  l)cni,nn.  \\  hile  -iipei(i(  i.al  |e,  ions  |)re(|oniiiiate,  deep  tuber- 
culous uicerat  ion  occasionallx  takes  place.  i,e\y  lias  recently  shown 
a  typical  deep  ulceratK.m  extending  tu  a  necrotic  alveolar  process,  the 
diagnosis  being  confirmed  by  examination  of  the  infected  tissues,  in 
which  were  found  well-defined  tuliercles  and  few  tubercle  bacilli.  He 
has  also  exhibited  a  series  of  very  interesting  tuberculous  lesions,  involv- 
ing the  hard  ]).alate.  soft  iialate,  and  i(in-ils.  Tuberculosis  of  the 
lips  is  very  unconnnon.  and  corresponds  more  or  less  to  the  slow 
benign  variety  of  tuberculous  lesions  of  the  skin,  i.  e.,  lupus  vulgaris. 
Unlike  tuberculous  affections  of  the  pharynx,  soft  palate,  or  tonsils, 
the  lesions  are  pos.sessed  of  but  very  slight  importance,  as  they  influence 
almost  to  no  extent  the  general  j^rognosis. 

Tuberculosis  of  the  .sop  piiloli  ii,i<l  jihariiii.r  is  relatively  infrequent, 
but  when  present,  constitutes  a  mo-t  distressing  form  of  the  disease. 
As  a  rule,  the  lesions  are  acti\c  and  ia|iii||y  progressive,  corresponding 
to  a  malignant  type  in  contradistinction  to  the  local  processes  involving 
the  tongue,  gums,  hard  palate,  and  lips.  'I'hese  a.re  more  frequently 
sluggish,  and  in  many  instances  result  from  i)urel.y  local  infection. 
When  the  soft  palate  and  pliar>ii\  .ire  involved,  a  beginning  pallor 
is  usually  observed,  with  or  ^\itliout  a  slight  edematous  swelling.  With 
the  thickening  of  the  mucous  niemlnane  there  may  be  noticed  the 
appearance  of  small  tubercles,  which  are  seen  as  tiny  j-ellowish-gray 


(■>~arilv 

results    lVi)m 

-a.       Sc 

vri'al    times   I 

i;,,i, 

1   |iliai'}-iix  in 

1  \      >lll!ll 

'  Kcccn 

tly  there  has 

>li-ht  1 

riss  of  weight 

IdUS    lllc( 

-ra-tion  of  the 

.n-l„.|n 

re  imlniniuuy 

(■    rlu.>t 

(liselose.l  the 

■ticill      Ul 

latlericlea    by 

464  COMPLICATIONS 

spots.     Ulceration  soon  takes  place,  attended  with  pain,  which  is  espe- 
cially severe  upon  deglutition. 

The  local  condition  is  often  an  accompaniment  or  expression  of  a 
general  miliary  invasion.  It  may  (n-cur,  however,  in  the  latei  stages 
of  pulmonary  tuberculosis,  when  the  sticimih  of  tlie  patient  is  well- 
nigh  exhausted,  and  the  retention  of  simtiini  in  the  pharynx  is 
favored  by  benumbed  local  sen-iMliiies  and  (hiuiuished  ex]iulsive 
power.  It  must  not  be  assume. 1,  (le.-]iiie  ihese  unusual  opportunities 
for  local  infection,  that  the  tubercle  (h  pcisi 
the  inward  penetration  of  tin  pli.n  \iiueal 
have  seen  tuberculous  ulceraiinu  ot  the  s( 
strong   and  robust  individual-   exluliitinu   b 

come  lUlilei-  m\'  ol  i-ei'\-.al  ii  in   a   L-elillenian   wit 
andstren-th,  i.ut  exIulntuiL;  w,  ll-.leluie.l  tubercuh 
po.sterior  wall  of  the  pharynx,  whiih  di^xehipeil  |( 
involvement  was  suspected.     Exaniinaumi  (n   ih 
presence  of    a  slight    quiescent    iiulm(inai\    inle. 
expectoration. 

Attention  has  been  called  to  the  frequency  of  tonsillar  infection  in 
pulmonary  phthisis,  aufl  to  the  occasional  presence  of  bacilli  in  the 
tonsils  III'  inili\-iiluals  exhiliitim;-  no  s\-mptiims  of  tubeiTuloiis  disease. 
The  rii.'xi^lenee  iil  |,.ra||/,.,|  iniiMllar  lul.en  iili.-i-  ni  the  miiLst  of  far- 
advaneeil  pulnii.uar\  plillii  i<  r-  suinelimes  i  lenmusl  rable,  but  the  role 
of  the  tnn-il  ni  inu  linmim  iii\ariably  an  open  pathway  of  infection 
to  the  ier\iial  '^laud-  r-  -iilijeri  \n  siime  question,  Jacobi  has  re- 
cently ca  lied  .atteiiiiim  111  reiiain  iliniral  and  anatomic  facts  which 
prejudice  strongly  the  likelilKi.iil  nf  lieipient  sysiemir  in\asi(in  by 
way  of  the  tonsil.  He  rites  the  (■(unparalnelx  lew  changes  whieii 
take  place  in  the  cei-xical  lymphaiir  ^'laiul-  in  luuneci  inn  with  inllani- 
matiou  111' llie  liiii-^iN  amla-umes  llial  a  live  rDiiuniimrat  ii  in  bet  ween 
the  tun  il  all.!  Ilie  -\-teni  b\  v,a\  ui  llie  b-  m|  ballr-  1-  pieveliled  bv 
a  dense  Jibruu-  Mrunuiv  ui|.'i\ruiim  beluei  n  llie  liin-illar  li<sue  and 
the  site  111  it-;  implaiitallnu.  lie  believes  that,  as  a  re-iill  nl  repeated 
acute  anil  rlirimir  iu(lainma1iir\-  ehaimes  in  the  lon-il.tlie  ti-Mie<iu  adult 
life  are  remleivil  less  uerniealile  m  barillarv  invasion  than  in  inlam-v. 

Althoimh  ill  aibaiireil  pliilii  i<  ilie  romlitions  are  such  as  to  afford 
unusual  nppoii  unii  ies  liii  iuieiiion  nl  lonsillar  crypts,  yet  there  may  be 
no  macroM-opir  exnleiire-  ol  lubeiriiliius  in\  ol  \ement.  Genuine  tuber- 
cle deposit  may  be  recognized  by  very  small  grayish  spots  scattered 
here  and  there  over  a  pale,  edematous  tonsil.  Irregular  ulcerative 
processes  are  sometimes  present. 


Tuhrirulnxis    oj    Ihr 

rsophn,,. 

i/N  is  extremely   rare,    and    takes    place 

almost    in\ariabl\-    as    ; 

:,    result 

111'  extension  "from  media-iinal    ulands. 

Even  ainiiim   consump 

licted  to  the  habit  of  swallowiim   their 

sputum    the    roliilili.ili- 

.are   -ue 

h   a-  almost    to  prerliuie  .au  involvement 

of  theesiipliaue.al  niur. 

i-a.      Till 

•  Miioolli   -iralilieil  epithelium  .asMiredlv 

is  not    i-alriilaled    In   at' 

bud   :,    I. 

iiluiUUiil.are    lor    b.arilli    -Wept    downward 

with  a  bolus  ol  inlerii'i 

1   looib 

.\t  the  same  time  individuals  who  have 

become    so    exIi.auMeil 

bv      till 

■    disease    as    involuntarily    to    swallow 

their  sputum  are  a  Inn 

Ki    sure 

to  siiiTunib  to  the  pulmonary  affection 

before   the   devrlojime: 

lit    of  esi 

iphaucal   tuberculosis.     It  has  been  re- 

corded,   however,    that 

tuberri 

ilous   nieiliastinal    glands  have   become 

acutely  inflamed  and 

adheren 

t  to  the  esojdiagus.     These  may  later 

ETIOLOGIC    AND    ANATOMIC    FACTORS  465 

undergo  caseation  and  perforate  the  esophageal  wall,  presenting  in  some 
instances  the  symptoms  of  stenosis.  Partial  occlusion  of  the  lumen 
may  take  place  without  perforation.  It  should  be  borne  in  mind  that 
symptoms  of  constriction  of  the  esophagus  are  sometimes  present 
without  the  slightest  encroachjnent  upon  the  lumen,  and  that  occasionally 
■actual  stenosis  is  unattended  by  subjective  symptoms. 

I  recall  two  cases  which  illustrate  both  of  the.se  clinical  phenomena, 
in  each  instance  confirmation  being  afforded  by  autopsy.  In  one  the 
patient  died  of  intercurrent  pnevmionia,  which  developed  after  removal 
to  the  hospital  for  esophagotomy,  following  very  pronounced  symptoms 
of  constriction  during  a  period  of  a  year  or  more.  The  autopsy,  con- 
ducted by  Dr.  Axtell  in  the  presence  of  Drs.  Powers,  Sewall,  and  myself, 
showed  no  pathologic  change  in  the  esophagus. 

The  other  patient  was  sent  to  Colorado  on  account  of  a  supposed 
tuberculosis.  The  clinical  manifestations  were  marked  emaciation 
and  cough,  in  the  ab.sence  of  all  symptoms  referable  to  the  esophagus. 
There  was  no  expectoration,  and  the  cough  was  decidedly  paroxysmal 
and  wheezy.  Physical  examination  was  negative,  save  for  the  recog- 
nition of  sibilant  rales  throughout  the  lungs.  The  clinical  picture 
suggested  compression  of  the  trachea,  which  was  apparently  con- 
firmed by  the  fluoroscope.  The  patient  expired  after  a  few  weeks 
from  suffocation,  and  the  autopsy  disclosed  the  presence  of  an  esophageal 
tumor,  which,  although  not  tuberculous,  is  worthy  of  mention  as  illus- 
trating the  lack  of  relation  between  the  pathologic  change  in  the  esopha- 
geal wall  and  the  subjective  symptoms. 

Kiimmel  has  recently  reported  an  extraordinary  case  of  esophageal 
tuberculosis  in  a  patient  fifty-two  years  old,  alcoholic,  and  suffering 
from  pulmonary  infection.  Four-fifths  of  the  entire  esophagus  was 
involved  in  the  tuberculous  ulceratinii.  mul  yet  no  clinical  symptoms 
were  noted  pointing  to  an  affection  of  the  i"S(i|>luigus. 

Von  Schrotter  reports  two  cases  i>\  tulK'iculosis  of  the  esophagus 
recently  observed,  in  each  instance  I  lie  iiireitimi  followiii'.;  a  primary 
involvement  of  the  right  lung,  with  :Mlhesiun  of  tlie  esopliai^eal  wall. 
The  diagnosis  was  made  by  direct  in.spectiou  of  the  lesions  with  the 


Tuberculosis  of  the  stomach  is  exceedingly  rare,  and  is  possessed  of 
but  slight  interest  or  clinical  importance.  It  has  resulted  occa.sionally 
from  the  extension  of  peritonenl  tiibereulosis.  The  possibility  of  a 
tuberculous  infection  ingrafted  upcui  the  site  of  an  open  gastric  or 
pyloric  ulcer  remains  a  somewliat  disputed  question.  In  general  the 
conditions  within  the  stomach  inimical  to  the  development  of  local 
tuberculosis  are  the  dilutiou  nf  the  bacilli,  the  muscular  movements, 
.ajid  the  acid  reaction  of  the  gastric  juice.  In  addition  to  these  factors 
Barchasch  calls  attention  to  the  scarcity  of  lymphatic  follicles  in  the 
stomach-walls,  and  believes  that  important  causes  in  the  develop- 
ment of  tuberculous  le.sions  in  the  stomach  relate  to  the  increase  of 
lymphoid  follicles  incident  to  chronic  gastric  catarrh.  He  suggests 
that,  inasmuch  as  the  pylorus  is  supplied  with  lymphoid  tissue  to  a 
greater  extent  than  other  portions  of  the  stomach,  possibly  stenosis  of 
this  region  is  tuberculous  oftener  than  has  been  supposed.  He  calls 
attention  to  the  tuberculous  ulcer,  the  miliary  tubercle,  the  solitary 
tubercle,  and  tumor-like  masses  in  the  stomach  closely  simulating 
•carcinoma. 


4bb  •  COMPLICATIONS 

CHAPTER   LXVII 
TUBERCULOSIS  OF  THE  INTESTINE 

Allusion  has  been  made  in  earlier  pages  to  the  results  of  pathologic 
research  and  experimental  study,  which  demonstrate  conclusively  the 
importance  of  the  digestive  tract  as  a  direct  avenue  for  the  primary 
invasion  of  the  system  by  tubercle  bacilli. 

Local  tuberculous  processes  in  the  intestinal  wall,  especially  in 
adults,  are  secondary  in  the  majority  of  instances  to  involvement  of 
other  parts.  They  undoubtedly  take  place  in  consumptives  as  the  re- 
sult of  unusual  local  exposure  to  infection,  with  an  added  vulnerability 
of  tissues  induced  by  virtue  of  the  original  disease.  Primary  tubercle 
deposit  in  the  intestine,  though  less  infrequent  than  formerly  supposed, 
is  decidedly  more  rare  than  the  secondary  infection.  Fiirst  has  collected 
the  histories  of  160  authenticated  cases  of  primary  intestinal  involve- 
ment. Many  cases  are  reported  by  such  authors  as  Demme,  Baginsky, 
Epstein,  Orth,  Kossel,  Lubarsch,  Eisenhardt,  Hermsdorf,  Ivlemperer, 
Wyss,  Ollivier,  Ganghofner,  and  Herterich.  Orth  reports  that,  from 
a  recent  observation  of  44  tuberculous  children,  primary  intestinal  tuber- 
culosis was  present  in  10  per  cent,  of  the  cases.  It  has  been  shown  that 
a  considerable  number  of  primary  lesions  of  the  intestine  were  caused 
by  tubercle  bacilli  of  the  bovine  type. 

Bovaird  has  called  attention  to  the  lack  of  uniformity  in  the  results 
reported  by  various  observers  regarding  the  prevalence  of  primary 
intestinal  infection  in  tuberculous  children  who  have  come  to  autopsy. 
Among  American  observers,  out  of  369  autopsies,  but  5,  or  IJ  per  cent., 
disclosed  a  primary  tuberculous  deposit  in  the  intestine.  The  Germans 
report  9  cases,  or  4  per  cent.,  out  of  236  autopsies.  From  among  128 
autopsies  reported  by  the  French  there  was  no  single  instance  of  primary 
intestinal  disease.  The  English,  however,  have  observed  136  cases,  or  18 
per  cent.,  out  of  748  autopsies.  After  allowing  for  the  apparent  dis- 
crepancies in  these  reports,  it  may  reasonably  be  inferred  that  primary 
tuberculous  lesions  of  the  intestine  occur  at  most  in  but  a  small  per- 
centage of  cases.  The  significance  of  the  preceding  statistics  is  enhanced 
by  consideration  of  the  fact  that  little  children  are  exposed  to  the  dangers 
of  infected  food  to  a  far  greater  extent  than  adults,  on  account  of  the 
preponderance  of  milk  as  an  article  of  diet,  and  the  much  greater  deli- 
cacy of  the  intestinal  structures. 

On  the  other  hand,  tuberculous  processes  in  the  intestine  are 
extremely  frequent  among  individuals  suffering  from  antecedent  pulmo- 
nary involvement.  In  the  Second  Annual  Report  of  the  Henry  Phipps 
Institute  for  the  Study,  Treatment,  and  Prevention  of  Tuberculosis 
White  reports,  out  of  a  total  of  143  autopsies  upon  consumptives,  45 
cases  exhibiting  well-defined  tubercle  deposit  in  the  small  intestine, 
involving  chiefly  the  ileum  and  the  vicinity  of  the  appendix.  During 
the  past  year,  out  of  57  autopsies  conducted,  tulierculous  ulcers  were 
found  in  the  jejunum  in  7  cases,  in  the  ileum  in  32,  and  in  18  cases  in 
which  the  location  is  not  cited. 

These  results  show  a  smaller  percentage  of  tuberculous  processes 
in  the  intestine  than  are  reported  by  other  observers.  According  to 
Oornet,  Eichhorst  found  intestinal  ulcers  in  21.9  per  cent,  of  462  au- 


TUBERCULOSIS    OF    THE    INTESTINE  467 

topsies  upon  pulmonary  invalids;  Heinze,  51  per  cent,  in  1226  cases; 
Honing,  in  70  per  cent.;  Weigert  and  Orth,  in  90  per  cent.;  and  Herx- 
heimer,  in  57  cases  out  of  58. 

It  is  noteworthy  that  local  processes  in  the  intestine  are  far  more 
common  than  in  any  other  portion  of  the  alimentary  tract.  Among  the 
various  causes  which  may  be  ascribetl  to  explain  the  relative  frequency 
of  infection  in  this  part  of  the  digestive  system  are  the  anatomic  structure 
of  the  epithelial  mucosa,  the  increased  absorptive  capacity  of  the  intes- 
tinal follicles,  the  absence  of  an  acid  medium  supposed  to  be  inhibitory 
to  the  activity  of  the  bacilli,  the  lessened  dilution  of  the  microorganisms 
after  the  absorption  of  the  assimilable  contents  thus  permitting  a 
closer  and  more  continuous  contact  with  the  mucous  membrane,  the 
separation  of  the  bacilli  from  the  protective  coating  of  mucus  in  the 
sputum  with  which  it  is  clothed  in  its  passage  from  the  pharynx  through 
the  esophagus  and  stomach,  and,  finally,  the  opportunities  afforded  in 
certain  parts  of  the  intestine  for  the  retention  of  microorganisms.  A 
brief  consideration  seriatim  of  these  factors  will  afford  perhaps  a  plausi- 
ble explanation  of  the  preponderance  of  lesions  in  this  portion  of  the 
alimentary  tract. 

Bacilli  are  enabled  to  penetrate  the  cylindric  epithelium  of  the 
gut  much  more  readily  than  the  stratified  pavement  epithelium  of  the 
pharynx  and  esophagus  or  the  epithelium  of  the  stomach.  Absorption 
takes  place  essentially  from  the  follicles  of  the  intestine,  in  which  imme- 
diate situation  the  tubercle  deposit  more  frequently  occurs.  The  follicu- 
lar structure  is  more  apparent  in  the  lower  portion  of  the  ileum;  the 
Peyer's  patches  are  the  more  common  seat  of  tuberculous  involve- 
ment. 

It  is  well  known  that  tubercle  bacilli  do  not  thrive  in  an  acid  medium, 
though  their  vitality  is  not  destroyed  by  the  hydrochloric  acid  of  the 
stomach.  The  alkaline  reaction  of  the  intestinal  contents,  while  perhaps 
not  distinctly  favorable  for  their  growth,  is  without  doubt  less  inimical  to 
their  activity  than  the  secretions  from  the  mouth  or  stomach. 

Tubercle  bacilli  gain  entrance  to  the  digestive  tract  largely  as  a 
result  of  contaminated  food  and  the  swallowing  of  infected  sputum  by 
consumptives.  If  bacilli  be  conveyed  at  meal  time  into  the  alimentary 
tract,  there  is  afforded  sufficient  dilution  almost  to  preclude  infection 
in  the  stomach  or  upper  digestive  canal.  With  the  absorjition,  however, 
of  the  liquid  portion  of  the  intestinal  contents,  barilli  w  liidi  do  not  enter 
the  chyliferous  ducts  are  relatively  more  abundant  in  ilic  solid  i-esidue, 
and  are  brought  into  more  immediate  and  prolonged  contact  with  the 
mucosa. 

In  view  of  the  comparative  rarity  of  primary  tuberculous  processes  in 
the  intestine  and  the  remarkable  frequency  of  local  lesions  among  con- 
sumptives, it  is  apparent  that  an  important  etiologic  factor  is  the  occa- 
sional introduction  of  tubercle  bacilli  into  the  alimentary  tract  with  the 
sputum  of  pulmonary  invalids.  Upon  entrance  to  the  digestive  canal 
there  is  often  such  an  admixfurc  of  tciuicious  mucus  as  to  encompass 
effectually  the  opaque,  semicaseous  ni:tsscs  of  s])utum  in  which  the  micro- 
organisms lurk  in  great  abundance.  .\s  a,  n>siilt  of  the  various  digestive 
processes,  the  protective  coatini^  of  bronchial  mucus  is  finally  separated 
from  that  portion  of  the  sputum  containing  bacilli.  Prolonged  contact 
with  the  intestinal' wall  is  thus  permitted,  e.specially  in  the  region  of 
the  appendix,  and  the  longer  the  stay  of  the  microorganism  at  a  given 


4b8  COMPLICATIOXS 

point  within  the  intestinal  canal,  the  greater  the  likelihood  of  local 
infection. 

Other  pockets  for  the  lodgment  of  tubercle  bacilli  are  found  in  the 
little  cUverticula  of  the  mucous  membrane  in  the  lower  portion  of  the 
rectum,  especially  just  above  the  anus.  These  are  often  of  considerable 
depth,  and  imbedded  to  some  extent  in  connective  tissue.  Slight  trauma- 
tism, which  not  infrequently  results  upon  a  small  scale  from  the  hardened 
and  inspissated  feces,  facilitates  the  colonization  and  invasion  of  bacilli. 
Further,  the  openings  of  the  tiny  lacunie  may  become  contracted  more 
or  less  in  an  analogous  manner  to  the  occlusion  of  the  proximal  end  of 
the  appenchx,  giving  rise  to  similar  inflammatory  changes.  Thus  may 
be  explained  the  development  of  suppurati\-e  processes  in  this  region 
resulting  in  the  production  of  anal  fistula.  Bacilli  are  frequently  dem- 
onstrated in  the  discharge,  but  it  has  not  been  shown  that  over  one- 
half  the  cases  of  rectal  fistula  are  positively  tuberculous  in  character. 
The  affection  is  not  uncommon  in  pidmonary  invalids,  but  it  is  doubtful 
if  a  large  percentage  of  the  patients  can  be  shown  to  be  definitely  tuber- 
culous. 

The  distinct  pathologic  features  pertaining  to  tuberculous  lesions 
of  the  intestine,  aside  from  their  location,  relate  either  to  the  ulceration 
of  the  nodules,  or  to  the  thickening  of  the  intestinal  wall  as  a  result  of 
fibrous  tissue  proliferation  after  the  manner  of  the  pleura  and  perito- 
neum. Two  distinct  ti/pes  of  intestinal  tuberculosis,  therefore,  are  recog- 
nized— the  ulcerative  and  the  hiiper plastic. 

Irrespective  of  the  nature  of  the  tuberculous  change  the  part  chieflj' 
involved  is  the  cecum  and  its  immecUate  neighborhood.  Either  form 
of  the  cUsease,  however,  may  extend  upward  into  the  intestinal  tract, 
involving  the  jejunum  and  duodenum,  or  downward  into  the  ascenchng, 
transverse,  or  descencUng  colon,  and  even  affect  the  sigmoid  flexure  and 
rectum.  Fenwick  and  Dodwell  report  that  out  of  a  total  of  883  cases 
of  tuberculous  involvement  of  the  intestine  observed  at  autopsies  per- 
formed upon  20,000  intUviduals  dying  of  tuberculosis  in  the  Brompton 
Hospital  for  Consumption,  ulceration  of  the  intestine  was  found  in  500 
cases,  or  56.6  per  cent.  The  ileocecal  region  was  the  seat  of  the  cUsease 
in  85  per  cent,  of  these  cases,  and  in  nearly  10  per  cent,  the  tuberculous 
infection  was  confined  to  this  region.  In  28  per  cent,  of  the  cases  there 
was  involvement  of  the  jejunum,  in  3.4  per  cent,  of  the  duodenum,  in 
51.4  per  cent,  of  the  ascending  colon,  in  21  per  cent,  of  the  descencUng 
colon,  in  13.5  per  cent,  of  the  sigmoid  flexure,  and  in  14.1  per  cent,  of 
the  rectum.  It  is  sometimes  possible  to  demonstrate  visually  the 
existence  of  tuberculous  ulcei-s  in  the  rectum,  from  four  to  eight 
inches  from  the  anus,  by  means  of  the  proctoscope  and  reflected  light 
with  the  patient  in  the  knee-chest  position.  In  one  patient  the  ulcers 
in  this  region  were  treated  locally  for  a  considerable  period  by  Dr.  Jayne 
and  myself  without.  howe\-er,  very  satisfactory  results. 

Ulcerative  Type. — The  intestinal  ulcerations  vary  in  size,  shape, 
depth,  and  in  their  disposal  upon  the  wall  of  the  gut.  The  ero.'^ion  is 
sometimes  superficial  in  character,  extending  merely  to  the  submucous 
tissue,  and  at  other  times  involves  the  entire  wall  of  the  inte.stine  and 
even  perforates  into  the  peritoneal  cavity.  The  size  varies  from  a 
minute  point  of  ulceration  in  the  center  of  a  nodule  covered  with  epi- 
thelium, to  a  discrete,  fairly  circular  erosion,  which  occasionally  assumes 
the  dimensions  of  a  large  bean  or  a  dime.     Even  larger  size  may  some- 


TUBERCULOSIS    OF    THE    INTESTINE  469 

times  be  attained  by  the  coalescence  of  several  individual  areas  of  ulcer- 
ation, in  which  event  the  outline  becomes  very  irregular.  The  shape 
of  discrete  ulcerations,  as  a  rule,  is  round  or  oval,  but  not  infrequently 
the  lesion  becomes  elongated  and  is  chsposed  around  the  wall  of  the 
bowel,  the  long  axis  being  transverse  to  that  of  the  intestine.  The 
borders  of  the  ulcer  may  be  infiltrated  or  exhibit  overhanging  edges. 
The  floor  presents  a  more  or  less  characteristic  grayish  appearance,  and 
is  sometimes  studded  with  small  nodules,  with  at  times  slightly  reddish 
projections.  Cicatrization  of  tuberculous  ulcers  is  not  frequent,  but 
takes  place  occasionally,  instances  of  intestinal  stenosis  confirmed  by 
autopsy  being  reported  from  this  cause. 

The  hyperplastic  form  of  intestinal  tuberculosis  is  characterized 
by  extensive  connective-tissue  formation,  producing  at  times  an  enor- 
mous thickening  in  the  wall  of  the  bowel,  which  is  usually  more  or  less 
localized.  Prior  to  1891  occasional  instances  of  intestinal  tuberculosis 
were  reported,  in  some  cases  there  being  a  definable  tumor  and  in 
others  a  stricture  of  the  bowel.  A  genuine  hyperplastic  type  of  tuber- 
culosis of  the  intestine  was  not  recognized  until  Hartman  and  Pilliet 
described  the  condition  in  detail.  Eight  or  nine  years  later  Lartigau 
and  Motel  presented  a  histologic  record  of  cases  reported  by  various 
observers.  Nancrede  has  recently  published  an  illustrative  case  coming 
under  his  observation,  and  has  reviewed  at  some  length  the  literature 
pertaining  to  the  sul)ject.  Fairly  numerous  cases  have  been  reported, 
exemplifying  in  their  description  the  conspicuous  feature  of  fibrous 
tissue  hyperplasia  resulting  from  local  tuberculous  infection.  This 
form  of  intestinal  tuberculosis  is  associated  at  times  with  a  varying 
degree  of  stenosis  of  the  bowel.  The  indurated  condition  may  be  con- 
fined to  a  circumscribed  region,  usually  in  the  neighborhood  of  the 
cecum,  but  occasionally  extensive  areas  of  the  intestinal  wall  are 
involved.  A  considerable  dilatation  of  the  bowel  may  exist  above  the 
seat  of  the  obstruction.  This  may  be  followed  liya  coiuiicnsutory  hyper- 
trophy of  the  wall  in  an  effort  to  overcome  the  initial  ocrjusion.  As  a 
result  of  localized  hyperplastic  change  a  distiucily  iJaliiaMe  tumor  is 
sometimes  recognized,  giving  rise  to  errors  of  diagnosis  on  account  of 
confusion  with  carcinomatous  and  syphilitic  neoplasms.  I  recall  a  single 
instance  of  this  hyperplastic  type  of  localized  intestinal  tuberculosis 
occurring  in  conjunction  with  similar  processes  in  the  peritoneum.  The 
obstruction  of  the  bowel  was  located  in  the  region  of  the  sigmoid  flex- 
ure, but  the  precise  nature  of  the  condition  was  not  established  until 
the  time  of  operation,  the  patient  being  under  the  observation  of  Drs. 
Bagot,  Craig,  Powers,  and  myself. 

Hartman  calls  attention  to  the  fact  that  these  tuberculous  hyper- 
plastic processes  resemble  closely  in  aspect  and  evolution  syphilitic 
changes  in  the  bowel. 

Baum  has  recently  reported  seven  cases  of  ileocecal  tuberculosis 
treated  by  operation,  and  describes  the  pathologic  condition  to  be  a 
benign  hyperplastic  form  of  primary  tuberculosis,  the  macroscopic 
appearance  of  which  resembles  the  hypertrophic  form  of  lupus,  with 
tubercle  bacilli  relatively  infrequent.  It  is  probable,  as  stated  pre- 
viously, that  these  apparently  benign  primary  cases  are  often  produced 
by  the  bovine  bacillus,  but  it  must  not  be  assumed  that  all  cases  of 
hyperplastic  intestinal  tuberculosis  are  of  benign  character.  Quite  to 
the  contrary,  it  is  found  that  in  the  majority  of  instances  they  are 


470  COMPLICATIONS 

possessed  of  the  greatest  ultimate  significance.  To  be  sure,  the  develop- 
ment is  often  slow  and  insidious,  without  appearance  of  definite  symp- 
toms, but  the  hyperplastic  growth  relentlessly  increases  in  size,  and 
without  operation  eventually  results  in  a  fatal  termination.  The 
clinical  onset  is  sometimes  acute,  and  closely  simulates  the  classic  reac- 
tion exhibited  in  appendicitis.  This  was  true  to  a  marked  extent  in 
the  case  previously  cited,  and  also  in  a  conspicuous  instance  of  hyper- 
plastic involvement  of  the  appendix,  to  be  reported  presently. 

The  practical  interest  regarcUng  ulcerative  tuberculous  processes 
of  the  intestine  among  consumptives  relates  principally  to  the  frequent 
digestive  disturbances  and  the  unfortunate  effect  upon  the  general 
condition. 

The  chief  clinical  manifestations  of  the  non-acute  type  of  hyperplastic 
involvement  are  the  S3'mptoms  of  gradually  increasing  intestinal  obstruc- 
tion and  the  existence  of  a  discoverable  tumor  upon  palpation. 

Treatment. — Tuberculosis  of  the  bowel,  regardless  of  the  particular 
type  of  the  disease,  is  frequently  amenable  to  surgical  management. 
Several  times  it  has  been  pointed  out  that  in  the  presence  of  tuberculous 
processes  involving  the  gut,  the  intestine  tolerates  radical  surgical  inter- 
ference to  a  far  greater  extent  than  in  the  miilst  of  other  pathologic 
conditions.  McArthur  has  called  attention  to  the  practice  of  excision 
or  exclusion  in  these  conchtions,  and  reports  five  cases  of  extensive 
tuberculous  involvement  which  have  resulted  in  prompt  recover}' 
following  operation.  His  views  coincide  with  those  of  Baum  as  to  the 
expediency  of  resection  whenever  the  contlitions  permit  its  perform- 
ance. This  is  more  applicable,  as  a  rule,  to  the  hyperplastic  type  than 
to  the  ulcerative,  on  account  of  the  more  circumscribed  area  of  the 
involvement  and  the  more  favorable  condition  of  the  patient.  This 
method  of  surgical  procedure,  however,  is  permissible  even  in  the  ulcer- 
ative variety,  provided  too  great  an  area  is  not  chseased  and  the 
exhaustion  with  loss  of  nutrition  not  excessive. 

The  simpler  method  of  exclu.sion  or  intestinal  anastomosis  may  be 
practised  when  the  extent  of  the  disease  and  the  debility  of  the  patient 
would  preclude  the  major  operation.  Hartman  reports,  from  a  review 
of  the  literature,  229  operative  cases  with  46  deaths. 

By  means  of  intestinal  anastomosis  following  a  fresh  implantation 
of  the  unaffected  portions  of  the  bowel  very  extensive  parts  of  the  intes- 
tine may  be  excluded,  with  relief  of  previous  distressing  symptoms  in 
individuals  incapable  of  withstanding  the  shock  incident  to  the  per- 
formance of  excision.  It  is  remarkable,  however,  to  what  extent  por- 
tions of  the  bowel  may  be  resected  successfully,  even  in  patients  exhibit- 
ing evidences  of  marked  exhaustion.  A  case  in  point  is  that  of  an 
individual  to  whom  I  urged  resection  of  the  bowel  in  1898.  Despite 
a  loss  of  over  60  pounds,  together  with  much  prostration,  six  inches  of 
the  ileum,  the  cecum,  all  of  the  ascending  colon,  two-thirds  of  the  trans- 
verse colon,  and  most  of  the  omentum  were  removed  by  Dr.  Rogers, 
followed  by  complete  recovery. 


TUBERCULOSIS    OF    THE    APPENDIX  4/1 

CHAPTER   LXVIII 
TUBERCULOSIS  OF  THE  APPENDIX 

Tuberculosis  of  the  appendix  has  been  shown  by  autopsy  observa- 
tions to  be  a  frequent  condition  among  advanced  pulmonary  invalids. 

In  a  series  of  autopsies  conducted  upon  consumptives  at  the  Phipps 
Institute  tuberculous  ulcers  of  the  appendix  were  found  in  44  out  of  143 
cases,  but  this  proportion  of  about  one  to  three  must  not  be  regarded 
as  a  fair  basis  upon  which  to  compute  its  general  frequency  among  pul- 
monary invalids  as  a  class.  It  must  be  remembered  that  the  condition 
of  the  appendix  among  individuals  dying  of  far-advanced  phthisis 
a,ffords,  for  the  purposes  of  comparison,  no  accurate  data  upon  which  to 
base  conclusions  relative  to  the  frequency  of  similar  involvement  in 
patients  exhibiting  less  extensive  pulmonary  infection.  In  the  one 
instance  the  victim,  after  a  more  or  less  prolonged  illness,  has  suc- 
cumbed to  an  advancing  infection  following  greatly  diminished  indi- 
vidual resistance  and  with  exceptional  opportunities  for  invasion  of 
intestinal  tissues.  In  the  other,  the  essential  consideration  relates  to 
the  fact  that  the  patient  is  still  alive  and  maintaining,  with  varying 
success,  the  struggle  to  promote  an  arrest  of  the  activity  of  the  tuber- 
culous processes,  other  tissues  frequently  becoming  resistant  to  attack. 
Necropsy  reports  with  reference  to  tuberculosis  of  the  appendix,  there- 
fore, may  be  regarded,  from  a  clinical  standpoint,  as  more  or  less  neg- 
ligible quantities. 

Ample  means  are  undoubtedly  offered  for  a  protracted  sojourn  of 
tubercle  bacilli  in  the  blind  appendiceal  pouch,  even  to  a  greater  extent 
than  in  the  cecum.  If,  in  addition  to  the  indeterminate  retention  of 
the  bacilli  in  the  appendix,  one  considers  the  various  influences  leading 
to  erosions  and  the  other  inflammatory  and  degenerative  changes,  it  is 
easy  to  appreciate  the  favorable  conditions  afforded  for  the  develop- 
ment of  tuberculous  ulcers. 

Great  practical  importance  attaches  to  the  surgical  findings  at  the 
time  of  operation  and  the  character  of  previous  manifestations.  Tuber- 
culosis of  the  appendix,  as  of  the  intestine,  has  been  found  to  exist  in 
two  distinct  types — the  nlcerative  and  the  hyperplastic.  The  former  is 
much  more  common,  and  usually  occurs  in  association  with  tuberculous 
lesions  of  the  intestine,  while  the  latter  variety  is  relatively  infrequent 
and  characterized  by  an  extensive  connective-tissue  hypertrophy.  In 
either  type  of  appendicular  tuberculosis  the  process  is  in  many  instances 
coexistent  with  ileocecal  disease.  It  is  often  impossible  to  assert,  from 
the  surgical  or  pathologic  data,  whether  or  not  the  tuberculous 
developed  simultaneously  with  the  intestinal  lesions.  While  the 
of  the  appendix  is  usually  coeval  with  a  corresponding  affection  of  the 
cecum,  it  has  been  shown  that  the  process  may  occasionally  be  limited 
to  the  appendix,  but  very  rarely  occurs  in  the  cecum  without  appendi- 
cular involvement.  In  Fenwick  and  Dodwell's  report  regarding  the  site 
of  tuberculosis  of  the  intestine,  to  which  allusion  has  been  made,  it  is 
stated  that  the  appendix  was  found  diseased  in  nearly  every  instance 
of  ileocecal  infection,  which  comprised  85  per  cent,  of  the  cases.  In 
seventeen  instances  the  appendix  was  the  only  portion  exhibiting  evi- 
dence of  tuberculous  change. 


472  COMPLICATIONS 

Primary  tuberculosis  of  the  appendix  without  discoverable  lesion 
of  the  intestine  or  other  parts  of  the  body  is  extremely  infrequent. 
Deaver  doubts  if  any  perfectly  authenticated  case  has  ever  been  reported. 
Kelly  described  six  cases  of  primary  appenchceal  tuberculosis,  one  of 
which  occurred  under  his  own  observation,  the  others  being  reported  by 
Cullen,  Sonnenberg,  Henrotin,  Crowden,  McCosh,  and  Hawkes.  He 
assumes  the  condition  to  be  primary  in  character,  because  the  clinical 
evidences  pointed  strongly  in  this  direction,  and  asserts  a  confirma- 
tion of  this  belief  by  the"  fact  that  the  removal  of  the  appendix  was 
followed  by  recovery.  In  no  instance  was  the  tuberculous  character  of 
the  appendiceal  involvement  suspected  until  the  specimen  was  subjected 
to  routine  histologic  examination.  This  latter  fact,  in  connection  with 
present  knowledge  concerning  the  latency  of  tuberculosis  and  the  im- 
prisonment of  the  bacilli  within  tissues  and  organs  presenting  no  abnor- 
mal macroscopic  appearance,  would  seem  to  constitute  in  itself  insuffi- 
cient evidence  to  justify  positive  conclusions  as  to  the  primary  form  of 
the  appendicular  affection. 

Failure  to  discover  definite  evidence  of  tubercle  deposit  in  any  portion 
of  the  body  upon  post  inoi  ten  1  ixa  mi  nation  scarcely  warrants  the  absolute 
exclusion  of  a  concealcil  TiilnrriiliiM-  inicction,  particularly  in  glandular 
tissues.  If  the  absence  of  autopsy  lim lings  does  not  always  justify  the 
elimination  of  a  possible  tuberculous  focus  in  a  remote  portion  of  the 
body,  still  greater  difficulties  must  attend  the  exclusion  of  such  infec- 
tion solely  upon  the  basis  of  the  clinical  evidences  during  life.  Further, 
the  mere  recovery  of  the  patient  after  operation  affords  an  insufficient 
basis  for  the  assumption  of  a  primary  lesion  of  the  appendix.  This 
course  of  remark  is  not  intended  to  reflect  in  the  least  upon  the  po.ssi- 
bility  of  primar\-  tubciculous  involvement  of  this  region,  but  rather  to 
suggest  the  insiiifiiicni  y  of  the  data  upon  which  such  views  are  neces- 
sarily based.  As  a  matter  of  fact,  the  infrequency  of  primary  infection 
of  the  appentlix  appears  somewhat  remarkable  in  view  of  the  fact  that 
the  anatomic  conditions  particularly  favor  the  development  of  tubercu- 
lous processes  at  this  point  in  preference  to  any  other  portion  of  the  intes- 
tinal tract  Assuming  the  introduction  of  bacilli  into  the  digestive  canal, 
the  ap])eiiilix  shoMJ,!  afford  the  most  natural  site  for  infection,  on  account 
of  the  icteiitiou  of  its  contents  and  the  receptivity  of  soil  induced  by 
frequent  mflainmatoiy  and  degenerative  changes.  That  instances  of 
supposed  |iiiiiiar\  t ul ieii'ilo>is  of  this  portion  of  the  intestine  are  not 
more  fic(|uently  repoite.l  is  explainable  by  the  non-appearance  of  macro- 
scopic clutnge  ami  tlie  aii-eiicc  of  lii-tolo-i.'  examination. 

In  very  niaii\  ca-es  there  i^  no  di-tui'/ui-lunii  characteristic  of  tuber- 
culous infection  to  lie  ivi-o-iiized  uiion  \i>ual  examination,  the  condition 
apparently  confurniuig  to  the  various  types  of  inflammation.  In  some 
instances,  however,  the  detection  of  the  nature  of  the  involvement  is 
rendered  easy  by  the  presence  of  small  tuberculous  nodules  upon  the 
peritoneal  covering. 

In  the  ulcerative  type  small  caseous  erosions  may  be  found  upon 
opening  the  appendix,  the  point  of  ulceration  conforming  to  the  general 
characteristics  of  tuberculous  ulcers  of  the  intestine  as  regards  shape, 
contour,  depth,  disposal,  and  appearance  of  the  floor  and  edges.  Suppur- 
ation sometimes  takes  place  as  the  result  of  a  secondary  infection.  The 
pus-formation  thus  induced  so  transforms  the  clinical  aspect  of  the  con- 
dition as  to  overshadow  the  element  of  tuberculous  infection.     It  is 


TUBERCULOSIS    OF    THE    APPENDIX  473 

reasonable  to  infer,  from  cumulative  clinical  experience,  that  the 
tendency  to  perforation  is  considerably  greater  in  cases  of  ulceration 
of  the  appendix  than  in  any  other  portion  of  the  intestinal  wall.  There 
is  but  little  pathologic  evidence  upon  which  to  hazard  an  opinion  as  to 
the  relative  frequency  in  the  appendix  and  cecum  of  cicatrization  and 
healing  by  fibrous  tissue  formation.  Surgical  experience,  however,  rela- 
tive to  the  discovery  at  operation  of  old  adhesions  and  extensive  fibrous 
tissue  change  suggests  a  somewhat  greater  tendency  toward  cicatrization 
in  the  appendix  than  in  the  intestine. 

The  hyperplastic  form  of  tuberculosis  of  the  appendix  represents 
the  same  type  of  pathologic  change  as  has  been  described  in  connection 
with  the  hypertrophic  variety  of  tuberculosis  of  the  intestine.  The 
condition  is  characterized  by  a  marked  increase  in  the  size  of  the  appen- 
dix, its  firm  consistency,  and  its  irregular  contour.  The  diameter  is 
often  increased  to  such  an  extent  that  the  cylindric  shape  is  entirely 
lost.  The  surface  is  smooth,  with  occasional  rounded  protuberances. 
The  wall  is  thickened  by  fibrous  tissue  proliferation,  which  some- 
times encroaches  upon  the  lumen  sufficiently  to  produce  a  genuine 
stenosis.  A  slight  degenerative  change  may  be  indicated  by  small 
yellowish  spots.  Areas  of  definite  caseation  and  softening  are  recog- 
nized upon  section.  The  microscopic  changes  are  similar  to  those 
described  as  obtaining  in  the  intestinal  hyperplasia  of  tuberculous  origin. 
Anatomic  tubercles  and  tubercle  bacilli  are  no  more  numerous  than  in 
the  preceding  condition.  The  con.spicuous  neoplastic  feature  of  this 
form  of  tuberculous  appendicitis,  especially  when  associated  with  ileo- 
cecal hypertrophy,  is  such  as  to  confound  the  condition  clinically  with 
new-growths  of  a  malignant  nature. 

In  plate  12  is  shown  a  tuberculous  appendix  of  the  hyperplastic 
type  removed  from  a  pulmonary  invalid  October  7,  1907.  This  case, 
which  is  of  unusual  interest,  will  be  reported  presently. 

Clinical  Symptoms. — The  symptoms  referable  to  this  form  are 
usually  more  pronounced  if  the  condition  is  accompanied  by  similar 
tuberculous  hyperplasia  of  the  cecum.  When  the  fibrous  tissue  change 
is  limited  solely  to  the  appendix  and  remains  uncomplicated  by  mixed 
infection,  there  may  be  but  slight,  if  any,  clinical  evidence  of  the  condition. 
A  connective-tissue  hyperplasia  of  the  cecum  and  appendix  jointly  is 
attended  by  pain  in  most  instances.  This  is  usually  of  a  subacute 
type,  but  there  are,  however,  occasional  severe  exacerbations,  vomiting, 
and  other  evidences  of  digestive  derangement.  There  may  be  indica- 
tions of  intestinal  occlusion,  with  the  demonstration  of  a  circumscribed 
ileocecal  tumor.  Should  a  purulent  process  supervene  in  the  appendix, 
there  ensue  the  well-known  manifestations  of  ordinary  suppurative 
appendicitis. 

The  symptoms  of  the  ulcerative  type,  which  is  of  more  common 
occurrence,  do  not  differ  essentially  from  those  of  non-tuberculous 
disease  of  the  appendix.  In  some  cases  the  subjective  signs  are  quite 
indifferent  and  even  devoid  of  suggestion  of  appendicular  disease.  At 
other  times  the  evidence  of  acute  or  chronic  inflammation,  perforation, 
and  peritoneal  extension  correspond  accurately  to  the  evolution  of 
symptoms  characteristic  of  non-tuberculous  appenditicis.  It  should 
be  emphasized  that  an  ulcerative  condition  of  the  appendix  of  tuber- 
culous origin  is  often  identical  clinically  with  ordinary  appendicitis. 
The   differential   diagno.sis   is   almost   always   impossible   without   the 


474  COMPLICATIONS 

laboratory  examination,  and  the  two  conditions  are  subject  to  the  same 
general  principles  of  management.  It  is,  therefore,  futile  among  pul- 
monary invalids  to  endeavor  to  discriminate  clinically  between  an 
ulcerative  tuberculosis  of  the  appendix  and  a  non-tuberculous  appendi- 
ceal involvement. 

Tuberculosis  of  the  appendix  may  exist  in  the  absence  of  discover- 
able tuberculous  lesions  in  other  parts  of  the  body.  While  pulmonary 
invalids  often  exhibit  the  classic  features  of  simple  acute  appendicitis, 
more  extended  histologic  examinations  may  reveal  in  the  future  its 
more  frequent  tuberculous  origin.  At  present  it  may  be  assumed  that 
this  condition  occurring  among  consumptives  is  not  necessarily  tuber- 
culous in  character.  Assuredly  it  does  not  conform  to  any  particular 
type  as  regards  the  clinical  manifestations  and  indications  for  treatment. 

Principles  of  Management. — Each  individual  case  of  appendicitis 
among  consumptives,  as  well  as  among  the  non-tuberculous,  must  be  . 
adjudged  in  accordance  with  the  established  principles  of  surgical  pro- 
cedure to  be  applied  according  to  the  merits  of  the  appendicular  indica- 
tions. It  should  be  remembered  that  the  exigency  relates  solelij  to  the 
appendiceal  disease,  and  not  to  the  pulmonary  involvement.  Measures 
to  avert  an  impending  general  septic  peritonitis  should  take  precedence 
over  a  chronic  condition  of  the  lungs  which  of  itself  is  often  self- 
limited.  Some  surgeons  confess  to  considerable  hesitation  in  perform- 
ing the  operation  for  appendicitis  upon  a  consumptive,  and  advise  delay 
unless  the  condition  is  especially  acute.  The  position  assumed  appears 
illogical  and  non-subservient  to  the  best  interests  of  a  class  entitled  to 
every  prompt  consideration.  It  is  true  that,  from  a  surgical  standpoint, 
the  responsibilities  are  greater,  and  perhaps  the  results  less  uniformly 
spectacular,  than  among  individuals  in  previous  good  health.  This 
does  not  alter  the  fundamental  truth,  however,  that  the  indications 
demanding  operation  among  the  non-tuberculous  obtain  to  an  equal 
if  not  greater  degree  among  consumptives.  On  account  of  the  dimin- 
ished resistance  of  these  invalids,  delay  is  often  more  disastrous  and 
attended  by  the  assumption  of  far  greater  moral  responsibility  by  the 
surgeon.  It  is  not  contended  that  the  consumptive  presents  in  all 
cases  the  same  possibilities  of  speedy  recovery  as  those  who  are  not 
afflicted  with  pulmonary  disease.  This,  however,  is  not  the  point  at 
issue  in  determining  the  choice  of  procedure  in  such  cases.  The  vital 
proposition  relates  to  the  question,  whether  or  not  the  existence  of 
pulmonary  tuberculosis  so  complicates  or  modifies  the  problem,  as  to 
preclude  upon  this  basis  alone  the  rendering  of  surgical  assistance. 

A  negative  decision  regarding  the  operation  is  not  justified  upon 
the  score  of  the  anesthetic  unless  the  pulmonary  disease  is  obviously  so 
far  advanced  as  to  render  recovery  impossible,  in  which  event  ordinary 
discretion,  of  course,  discountenances  operation.  It  has  been  shown, 
however,  in  a  previous  chapter,  that  it  is  often  impossible  to  assert  with 
positivcncss  that  a  given  case  is  beyond  hop&of  ultimate  arrest.  I  am 
well  awiir  ili.ii  the  decision  concerning  operative  interference,  even 
in  sini]ilc  :ipi>rii, Ileitis,  is  often  a  choice  of  the  lesser  of  two  evils,  and 
fraught  with  iiiaii\  anxious  responsibilities.  It  is  conceded  that  in  a 
judicial  estimate  of  tlie  relative  bearing  of  the  many  phases  pertaining 
to  an  individual  case,  the  existence  of  advanced  phthisis  may  in  excep- 
tional instances  constitute  the  determining  consideration,  and  justly 
turn  the  balance  of  argument  in  favor  of  delay.     Cases  of  this  character, 


TUBERCULOSIS    OF    THE    APPENDIX  475 

however,  do  not  comprise  the  category,  concerning  which  doubt  as  to 
the  expediency  of  operation  is  usually  expressed  by  surgeons.  As  a 
matter  of  fact,  the  bed-ridden  consumptive  rarely  exhibits  evidence  of  an 
appendiceal  involvement.  From  a  close  observation  of  over  2000  cases 
of  pulmonary  tuberculosis  I  can  recall  but  a  single  instance  of  appen- 
dicitis developing  in  the  last  stages,  and  in  this  case  Dr.  Powers  and  I 
quicidy  agreed  as  to  the  futility  of  surgical  intervention.  It  is  sub- 
mitted, however,  that  when  a  reasonable  doubt  is  entertained,  the 
invalid  should  be  accorded  the  benefit  of  the  doubt,  and  in  case  of 
emergency  receive  the  same  prompt  surgical  aid  as  the  non-tuberculous. 
In  the  presence  of  recognized  imminent  danger  from  fulminating  appen- 
dicitis, the  peril  of  the  consumptive  is  assuredly  no  less  than  his  more 
fortunate  fellow,  and  hence  the  rational  advocacy  of  equal  opportunity 
for  surgical  relief.  An  increased  liability  to  succumb  from  the  shock  of 
.the  operation,  even  if  true,  would  not  militate  directly  against  its  ready 
performance  in  the  face  of  conditions  clearly  indicative  of  its  necessity 
under  other  circumstances.  In  this  event  failure  to  survive  the  surgical 
ordeal  is  not  of  itself  condemnatory  of  the  operation.  On  the  other 
hand,  when  the  conditions  are  not  such  as  to  involve  a  reasonable  doubt 
concerning  the  propriety  of  the  operation,  no  hesitation  as  to  the  choice 
of  procedure  should  be  permitted.  In  other  woi'ds,  a  decision  as  to  the 
relative  advantages  and  disadvantages  of  the  early  and  interval  opera- 
tions in  such  cases  should  be  made  upon  the  merits  of  the  appendicitis 
itself,  precisely  as  among  individuals  previously  well,  without  taking 
cognizance  of  the  existing  pulmonary  affection.  Pulmonary  invalids, 
as  a  rule,  undergo  anesthesia  without  special  difficulty. 

Important  considerations  in  favor  of  operation  are  the  possibility  of 
an  abrupt  termination  in  the  absence  of  surgical  aid,  the  inevitable 
confinement  incident  to  prolonged  convalescence  among  non-operative 
cases,  and  the  added  difficidty  in  sustaining  nutrition  due  to  gastro- 
intestinal disturbances  so  often  incident  to  chronic  appendicitis  and  the 
ever-present  danger  of  relapse.  Failure  to  discover  definite  physical 
signs  in  the  right  iliac  fossa  in  the  presence  of  sudden  chill,  fever,  nausea, 
vomiting,  general  abdominal  pain,  and  prostration  affords  no  assurance 
whatever  of  the  non-existence  of  a  grave  appendiceal  condition.  The 
contention  is  made  that  in  appendicitis  there  is  no  constant  relation 
between  the  severity  of  the  symptoms  or  signs  and  the  nature  of  the 
pathologic  change  within  the  abdomen.  There  is  no  invariable  rule 
lay  which  to  hazard  an  opinion  concerning  the  existence  of  gangrene, 
perforation,  pus-accumulation,  circumscribing  adhesions,  or  localized 
peritoneal  involvement.  The  pathologic  condition,  without  opening 
the  abdomen,  is  at  best  a  mere  matter  of  conjecture,  even  in  the  absence 
of  unfavorable  symptoms.  A  considerable  experience  with  appendicitis, 
both  among  pulmonary  invalids  and  the  non-tuberculous,  confirms  the 
belief  that  it  is  impossible  in  a  given  case  to  describe  the  pathologic 
process  in  the  neighborhood  of  the  appendix  or  to  estimate  with  accuracy 
the  imminence  of  threatening  morbid  change. 

Some  years  ago  I  reported  several  cases  of  appendicitis  among 
pulmonary  invalids  whose  abdominal  pain  was  general  rather  than 
local,  witii  entire  absence  of  tenderness  or  resistance  over  the  region 
of  the  appendix  upon  careful  physical  examination.  In  two  of  these 
cases,  upon  opening  the  abdomen,  free  pus  was  found  in  the  general 
cavity,  with  an  exceedingly  long  appendix  dipping  over  and  below  the 


476  COMPLICATIOXS 

brim  of  the  pelvis,  where  the  tip  had  become  adherent.  This  position 
of  the  distal  end  amply  explained  failure  to  elicit  tenderness  or  rigidity 
upon  early  palpation,  in  spite  of  advanced  pathologic  change.  These 
cases  demonstrate  conclusively  that  a  genuine  involvement  of  the 
appendix  may  exist  without  the  exhibition  of  palpable  evidence, 
although  the  general  and  constitutional  symptoms  may  be  sufficiently 
definite  to  characterize  the  attack  as  a  most  serious  abdominal  condition 
of  some  kind.  Such  an  experience  estabhshes  the  fact  that,  in  the 
presence  of  severe  abdominal  pain  of  violent  onset,  with  change  in  pulse 
and  temperature,  even  despite  absence  of  rigidity  and  tenderness  over 
the  region  of  the  appendix,  an  absolute  exclusion  of  appendicitis  is 
quite  impossible  without  recourse  to  exploratory  laparotomy. 

It  may  be  regarded  as  unwarranted  for  an  internist  to  formulate  his 
own  ideas,  and  base  his  conclusions  as  to  a  general  course  of  action  in 
appendicitis  and  other  abdominal  affections,  from  his  comparatively 
restricted  opportunities  for  observation.  Irrespective,  howe^■er,  of 
the  degree  of  familiarity  with  the  recorded  results  of  others,  it  remains 
for  an  active  experience  to  crystallize  one's  views  and  define  a  general 
course  of  procedure  with  reference  to  this  condition.  Among  pul- 
monary invalids  as  well  as  the  non-tuberculous,  appendicitis  exhibits 
a  startling  prevalence,  and  an  unnecessarily  high  mortality  rate.  So 
long  as  the  dailj'  press  continues  to  record  frequent  deaths  from  a  disease 
which  at  some  period  of  its  course  is  recognized  by  the  medical  profession 
to  be  distinctly  curable,  so  long  will  there  remain  a  justification  for  its 
most  thoughtful  and  oft-repeated  consideration.  Although  obviously 
a  surgical  condition,  the  discussion  of  appendicitis  among  phthisical 
patients  appears  particularly  appropriate  in  a  work  devoted  to  pulmo- 
nary tuberculosis. 

The  position  assumed  by  the  attending  physician  concerning  this 
affection  is  sometimes  equivocal,  compromising,  and  most  unsatis- 
factory. Although  not  directly  involved  in  the  later  surgical  manage- 
ment of  the  disease,  he  is  compelled,  nevertheless,  to  accept  an  obligation 
fraught  with  infinitely  greater  responsibility  than  that  assumed  by 
the  surgeon.  It  so  happens,  in  the  majority  of  cases,  that  it  is  the 
physician,  rather  than  the  surgeon,  whose  professional  services  are 
sought  early  in  the  disease.  This  is  explained  not  only  by  the  abiding 
confidence  reposed  in  the  familj'  physician,  but  also  through  failure 
of  the  patient  or  friends  to  appreciate  fully  the  character  and  possi- 
bilities of  the  ailment.  Thus  it  is  that  at  the  very  time  when  the  hour- 
to-hour  question  of  management  is  all  vital  to  the  life  of  the  individual, 
the  case  is  rested  solely  with  the  physician,  the  fate  of  the  patient  often 
depending  upon  the  detail  and  accuracy  of  observation,  the  definiteness 
of  purpose,  and  the  promptness  of  action  during  the  first  twenty-four 
to  thirty-six  hours.  There  can  be  no  greater  reflection  on  the  pro- 
fessional attainments  and  acumen  of  a  physician  than  failure  to  recognize 
at  once  the  possible  nature  of  the  disease  and  to  arrange  for  operation 
at  an  opportune  time,  rather  than  to  summon  surgical  aid  after  a  period 
of  disastrous  and  delu.sory  expectancy.  Upon  the  development  of 
acutely  violent  abdominal  symptoms,  suggesting  appendicitis  or  per- 
forative peritonitis,  few  complicating  conditions  furnish  legitimate 
contraindications  for  operation.  In  such  an  emergency  the  mere 
existence  of  pulmonary  tuberculosis  affords  insufficient  grounds  for 
hesitation  or  delav. 


TUBERCULOSIS    OF    THE    APPENDIX  477 

A  substantiation  of  the  correctness  of  these  views  has  seemed  to  be 
afforded  from  my  experience  with  appendicitis  among  consumptives. 
An  early  operation  has  been  performed  upon  14  moderately  advanced 
pulmonary  invalids,  with  uniformly  favorable  results.  In  no  case  was 
there  occasion  to  regret  the  operation,  and  in  11  instances  it  is  fair  to 
assert  that  life  was  saved  through  immediate  surgical  aid.  In  3  cases 
it  was  impossible  to  conclude  with  positiveness  that  recovery  might  not 
have   talven   place   without   operation. 

In  addition  to  the  14  cases  of  early  surgical  interference,  3  others 
died  from  general  septic  peritonitis,  the  free  abdominal  cavity  in  each 
instance  being  filled  with  pus  at  time  of  operation.  None  of  these 
patients  succumbed  from  the  effects  of  the  operation  per  se,  as  the 
abdominal  condition  was  such  as  to  preclude  recovery.  In  all  cases 
the  anesthetic  was  admirably  borne.  Six  additional  consumptives, 
with  well-defined  appendicitis  for  whom  operation  was  not  advised, 
eventually  recovered  from  the  appendiceal  involvement,  while  one, 
refusing  operation,  died  after  a  few  days. 

Objection  has  been  made  by  some  to  operation  among  this  class 
of  patients  through  fear  of  a  protracted  convalescence,  the  formation 
of  multiple  abscess,  and  the  possibility  of  fecal  fistula.  I  have  never 
found  the  surgical  convalescence  unduly  prolonged  among  consumptives. 
Multiple  abscesses  have  never  been  observed  among  my  cases,  and 
there  has  been  but  one  case  of  fecal  fistula.  A  small  superficial  sinus 
developed  in  two  cases  after  operation,  but  subsequently  healed. 

For  the  purposes  of  illustration  I  will  report  briefly  several  cases  of 
operation  among  advanced  consumptives. 

ILLUSTRATIVE  CASES 

Case  I. — A  woman,  thirty-one  years  of  age,  came  under  my  observa- 
tion May  6,  1907,  two  years  after  the  development  of  pulmonary  tubercu- 
losis. Despite  a  sojourn  in  several  health  resorts  tlie  general  trend  of 
the  disease  had  been  downward.  There  was  a  loss  of  twenty  pounds 
in  weight,  with  ooiTesponding  diminution  of  strength,  a  moderate  tem- 
perature elevaliiJii,  :iiiil  slight  cough  and  expectoration.  The  appetite 
was  exceedingly  pnor  mid  digestion  much  impaired.  There  were  five 
or  six  loose  bowel  nioveuients  daily,  attended  by  considerable  abdominal 
pain.  Tubercle  bacilh  were  found  in  the  fecal  discharges.  The 
examination  of  the  chest  disclosed  extensive  tuberculous  involvement 
of  each  lung,  upon  the  right  side  the  infected  area  extending  from  the 
apex  to  the  third  rib  and  to  the  lower  angle  of  the  scapula;  upon  the 
left  side,  from  the  apex  to  the  base  in  front  and  to  the  middle  of  the 
interscapular  space.  Under  rigid  hygienic  and  dietetic  measures  a 
moderate  improvement  was  exhibited  from  May  until  October.  There 
was  an  increase  of  ten  pounds  in  weight,  with  gain  in  the  general  strength 
and  a  continuous  reduction  of  fever.  There  remained,  however,  con- 
siderable impairment  of  digestion,  with  loose  bowel  movements  and 
occasional  colicky  attacks  of  pain  of  short  duration.  Upon  October  4th 
she  experienced  severe  pain  in  the  right  iliac  region,  accompanied  by  a 
slight  rigor  and  vomiting.  This  was  followed  by  moderate  temperature 
elevation  and  acceleration  of  pulse.  The  abdomen  was  extremely 
tender  and  rigid  upon  the  right  side.  A  diagnosis  of  appendicitis  was 
made,  but  on  account  of  her  general  condition,  a  decision  as  to  the 


478  COMPLICATIONS 

advisability  of  operation  was  held  in  abeyance  for  a  few  hours.  Upon 
the  following  day  there  was  a  complete  remission  in  the  severity  of  the 
symptoms,  the  pain  disappearing  entirely,  the  temperature  returning 
to  normal,  and  the  pulse  to  96.  The  condition  of  the  abdomen,  however, 
was  unchanged.  No  food  was  administered  by  the  mouth,  and  further 
ilelay  appeared  justifiable.  During  the  evening  of  the  second  day  the 
patient  suffered  another  chill,  with  recurring  pain,  renewed  temperature 
elevation,  and  vomiting.  Immediate  operation  was  urged,  but  stub- 
bornly refused.  Despite  emphatic  insistence  upon  recourse  to  surgical 
measures,  consent  was  not  obtained  unil  the  morning  of  October  7th, 
the  temperature  in  the  mean  time  having  risen  to  103°  F.,  and  the 
pulse  to  136.  The  operation  was  performed  by  Dr.  Powers,  and  a 
tuberculous  appendix  of  the  hyporplnstic  type  was  removed.     Although 


Fig.  125.— Drawing  of  miliary  tuluM.!.-  of  ili.-  ;,,,,H'iidix.  (See  plate  12.)  Note  the  well- 
defined  connective-tissue  reticulum  aiui  tiie  i;iani-c-cll  in  tlie  center,  witli  circular  mural  dis- 
position* of  the  nuclei.     Note  central  areas  of  degeneration  and  cellular  proliferation  in  the  per- 

the  cecum  was  also  found  the  seat  of  similar  tuberculous  involvement, 
the  general  condition  of  the  patient  precluded  resection  of  the  bowel. 
The  patient  made  an  uneventful  recovery  from  the  operation,  although 
a  fecal  fistula  persisted. 

An  interesting  feature  of  this  case  was  the  diagnosis  before  operation 
of  the  tuberculous  nature  of  the  appendiceal  involvement.  This  is 
explained  by  the  fact  that  ^wsa  of  a  milligram  of  the  new  tubercuhn 
had  been  administered  less  than  twenty-four  hours  prior  to  the  develop- 
ment of  appendiceal  symptoms.  The  acute  onset  following  the  institution 
of  tuberculin  treatment  suggested  a  probable  relation  of  cause  and  effect 
in  the  way  of  a  local  and  general  reaction.  The  hard,  irregular,  and 
nodular  mass,  as  it  appeared  immediately  after  removal,  is  shown  in 
plate  12,  figure  1.  After  hardening  in  a  2  per  cent,  solution  of  formalin 
for  two  days,  the  mass  was  incised,  and  showed  well-marked  caseation 


% 


Fig.  1. — Hyperplastic  tuberculous  appendix  removed  from  pulmonary  invalid.  Note 
irregular  contour  with  rounded  protuberances.  The  needle  is  inserted  partly  into  the 
lumen.  Compare  with  following  illustration  representing  the  appendix  upon  section. 
The  histologic  appearance  is  shown  in  Fig.  12.5. 


Fig.  2. — Section  of  tuberculous  appendix  of  the  hyperphistic  type,  hardened  in 
formalin  for  two  days  before  being  incised.  Note  in  each  half  the  characteristic  tuber- 
culous ca-seation,  with  well-defined  areas  of  softening  and  partial  obliteration  of  the 
lumen.     Compare  with  preceding  illustration,  same  specimen. 


TUBERCULOSIS    OF    THE    APPENDIX  479 

with  small  areas  of  softening.  There  was  an  almost  complete  oblitera- 
tion of  the  lumen  of  the  appenciix.  The  appearance  of  the  specimen  at 
that  time  is  shown  in  plate  12,  figure  2.  Typical  tubercle  formation 
was  recognized  upon  microscopic  examination,  as  shown  in  the  accom- 
panying illustration  (Fig.   125). 

Case  II. — The  patient  was  a  young  woman  who  came  under  my  obser- 
vation September  29,  1902,  when  twenty-one  years  of  age.  Four  members 
of  her  immediate  family  had  died  of  consumption.  Her  pulmonary 
involvement  had  been  of  two  and  one-half  years'  standing.  She  had 
resided  in  Colorado  for  two  years,  during  which  time  progressive  failure 
had  taken  place.  The  patient  was  greatly  emaciated,  exhibiting  con- 
siderable temperature  elevation  daily,  and  suffering  from  numerous  loose 
bowel  movements.  Tubercle  bacilli  were  found  in  the  rectal  discharges. 
There  was  extensive  tuberculous  ulceration  of  the  larynx.  The  exami- 
nation of  the  chest  showed  tuberculous  involvement  of  the  greater 
portion  of  right  lung,  without  cavity  formation.  After  the  lapse  of 
two  years  a  remarkable  improvement  took  place.  Abdominal  distention 
and  diarrhea  had  ceased  altogether,  cough  and  expectoration  had  mark- 
edly diminished,  the  weight  had  increased  over  thirty  pounds,  and  the 
tuberculous  involvement  of  the  larynx  had  improved  to  such  an  extent 
that  local  treatment  was  suspended.  The  examination  of  the  chest 
disclosed  an  evident  quiescence  of  the  tuberculous  process,  although 
complete  arrest  had  not  thus  far  been  secured.  Shortly  after  this  she 
married,  and  assumed  the  responsibilities  of  housekeeping,  following 
which  she  lost  in  weight  and  exhibited  renewed  activity  of  the  tubercu- 
lous infection.  In  July,  1905,  she  developed  a  typical  acute  appendicitis 
and  was  hurried  to  operation  a  few  hours  after  the  development  of  initial 
symptoms.  The  patient  had  not  been  under  medical  observation  for  , 
eight  or  ten  months  prior  to  this  time,  and  her  general  condition  was 
far  from  favorable.  The  operation  was  performed  by  Dr.  Dixon,  and 
a  much  enlarged  and  inflamed  appendix  removed.  The  patient  made 
a  prompt  and  uninterrupted  recovery.  At  present  there  are  no  signs 
of  activity  of  the  tuberculous  disease.  The  examination  of  the  chest 
is  negative,  with  the  exception  of  fibrosis.  There  are  no  bacilli  in  the 
sputum,  no  evidences  of  intestinal  disturbance,  and  a  complete  healing 
of  the  laryngeal  involvement. 

Case  III. — A  man  of  forty-eight  with  a  family  history  of  tubercu- 
losis came  to  Colorado  ten  years  ago  on  account  of  extensive  tubercu- 
lous involvement  of  the  left  lung.  After  several  years  of  rational  living 
there  was  secured  a  complete  arrest  of  the  tuberculous  process.  In 
1904  the  patient  experienced  a  beginning  digestive  disturbance,  with 
constipation,  intestinal  flatulence,  and  fleeting  attacks  of  pain  referred 
to  the  region  of  the  appendix.  As  a  result  of  the  digestive  disturbance 
and  impaired  appetite,  there  took  place  a  progressive  loss  of  weight  and 
strength,  accompanied  by  a  renewed  activity  of  the  tuberculous  process 
in  the  lung.  The  weight  was  reduced  nearly  forty  pounds  and  the 
vitality  much  enfeebled.  In  April,  1906,  there  was  a  sudden  attack 
of  pain  in  the  right  iliac  fossa,  without  vomiting  or  temperature  eleva- 
tion. There  was  absolutely  no  resistance  or  rigidity  of  the  muscles  of 
the  right  lower  abdomen.  The  face  was  pinched  and  ashen.  Upon  deep 
palpation  a  small  tumor  was  recognized  well  to  the  outer  edge  of  the 
abdomen.  Laparotomy  was  immediately  performed  in  spite  of  extreme 
prostration,    malnutrition,    and    active   pulmonary   tuberculosis.     The 


480  COMPLICATIONS 

decision  to  operate  was  based  in  part  upon  the  expediency  of  removing 
a  possible  cause  for  the  protracted  digestive  derangement.  It  was  felt 
that  even  a  disappearance  of  the  acute  stage  of  inflammation,  with 
remission  of  the  urgent  symptoms,  would  leave  the  patient  with  but 
slight  opportunity  to  secure  arrest  of  the  pulmonary  infection.  Operation 
performed  by  Dr^  W.  A.  Jayne  disclosed  a  much  elongated  and  thickened 
appendix,  with  beginning  gangrene.  The  patient  recovered  promptly 
from  the  effects  of  the  surgical  procedure,  and  has  since  attained  a 
complete  restoration  of  his  previous  health.  There  has  been  a  con- 
spicuous gain  in  weight  (25  pounds)  and  strength,  with  entire  absence 
of  physical  signs  of  the  pulmonary  affection. 

Case  IV. — A  boy,  nine  years  old,  was  brought  to  Colorado  June  1, 
1903,  after  several  months'  progressive  decline  in  New  Mexico.  There 
was  extensive  active  involvement  of  the  left  lung  and  a  moderately 
advanced  tuberculous  process  in  the  right.  There  were  great  emacia- 
tion and  physical  debility,  moderate  temperature  elevation  daily,  and 
an  exceedingly  weak  and  rapid  pulse.  No  hope  of  securing  an  arrest 
was  entertained.  After  three  months  of  complete  rest  in  bed  in  the 
open  air,  with  active  efforts  toward  superalimentation,  a  gain  of  fifteen 
pounds  wasestablishr-ii.  with  n  rresponding  improvement  in  the  general 
condition.  The  stren^ith  aiiaiu  was  reduced  by  a  six  weeks'  illness 
with  typhoid  fever,  upon  recovering  from  which  a  satisfactory  improve- 
ment in  the  general  condition  was  continued  until  January,  1905,  when 
an  appendicitis  developed  with  moderate  pain  and  vomiting.  There 
was  no  fever,  the  resistance  in  the  right  iliac  region  was  very  slight,  but 
the  pulse  was  1.30  and  of  poor  quality.  The  question  was  presented  as 
to  the  expediency  of  operating  upon  a  ten-year-old  boy  with  advanced 
phthisis  and  a  poor  general  condition,  in  the  absence  of  parents.  There 
was  some  hesitation  as  to  the  wisdom  of  surgical  interference  on  account 
of  the  lack  of  tenderness,  temperature  elevation,  and  rigidity,  suggesting 
that  the  condition  was  not  especially  acute.  After  some  hours'  delay 
it  was  decided  to  assume  the  responsibility  of  operation.  A  gangrenous 
appendix  was  removed  by  Dr.  Dixon,  and  speedy  recovery  ensued. 
Complete  arrest  of  the  pulmonary  tuberculosis  has  since  been  secured. 
Thff  child  has  been  at  home  for  over  two  years,  and  I  am  advised  exhibits 
no  evidence  of  icucwinI  activity  of  the  tuberculous  infection. 

Case  V. — The  patient  was  a  woman,  fort3--two  years  old,  who  arrived 
in  Colorado  in  June,  1906,  presenting  the  history  ofadvanced  pulmonary 
tuberculosis  of  four  years'  duration.  There  was  marked  loss  of  weight, 
dyspnea,  and  rapid  pul-p.  Eacli  lung  was  extensively  diseased,  an 
active  infection  beiui:  k-i  Mi^nizcd  upon  the  right  side  from  the  apex 
to  the  third  rib,  and  upon  ilu-  left  from  the  apex  to  the  fourth  rib, 
with  pronounced  pulmonary  excavation.  An  unfavorable  prognosis  was 
necessarily  entertained.  Improvement,  however,  was  noted  during 
a  period  of  two  months,  after  which  she  experienced  sudden  pain, 
nausea  without  vomiting,  moderate  elevation  of  temperature,  and 
increased  rapidity  of  the  pulse.  Very  slight  resistance  was  obtained 
in  the  right  iliac  region.  Immediate  operation  was  advised,  although 
due  cognizance  was  taken  of  the  responsibility  assumed  in  surgical 
interference  upon  a  case  of  this  character.  It  was  feared  that  if  the 
appendix  was  permitted  to  remain,  convalescence  would  be  unavoidably 
protracted,  and  alimentation  greatly  reduced.  An  acutely  inflamed 
and  elongated  appendix  was  removed  by  Dr.  Dixon.     The  subsequent 


TUBERCULOSIS    OF    THE    APPENDIX  481 

history  of  the  case  will  be  reported  in  connection  with  Clinical  Obser- 
vations upon  the  Use  of  Bacterial  Vaccines.  The  improvement  in  the 
general  and  pulmonary  conditions  has  been  pronounced. 

Case  VI. — A  pulmonary  invalid,  thirty-four  years  of  age,  while  in 
the  mountains  of  Colorado  in  the  summer  of  1906,  suddenly  experienced 
fairly  acute  abdominal  pain,  which  was  followed  by  chill  and  vomiting. 
After  remaining  in  bed  for  several  days  the  acuteness  of  the  pain  sub- 
sided somewhat,  and  the  general  condition  was  so  improved  as  to  permit 
his  undertaking  a  twenty-five-mile  ride  to  the  nearest  railway  station. 
By  the  merest  chance  I  met  the  patient  upon  the  way,  and  was  solicited 
to  render  medical  aid.  The  patient  was  emaciated,  extremely  pale, 
with  weak  and  rapid  pulse,  but  no  elevation  of  temperature.  Examina- 
tion made  at  the  time  showed  a  generally  distended  abdomen.  There 
was  no  especial  localization  of  the  pain  or  tenderness  in  the  region  of 
the  appendix.  The  patient  was  removed  to  Denver,  and  operation 
decided  upon  in  spite  of  a  poor  geheral  condition,  pulmonary  involve- 
ment, and  a  considerable  degree  of  uncertainty  as  to  the  precise  nature 
of  the  abdominal  disturbance.  A  circumscribed  ileocecal  abscess  was 
evacuated  by  Dr.  Powers,  but  efforts  to  discover  the  appendix  were 
unavailing.     The  patient  made  a  satisfactory  recovery. 

Case  VII. — A  woman,  thirty-two  years  of  age,  having  resided  in 
Colorado  for  four  years  on  account  of  an  extensive  tuberculous  involve- 
ment of  each  lung,  suddenly  experienced,  upon  November  30,  1905, 
severe  abdominal  pain  in  the  right  ileocecal  region.  This  was  attended 
by  chill  and  vomiting.  She  had  previously  secured  a  gain  of  about 
fifty  pounds  in  weight,  and  a  pronounced  improvement  in  the  pulmonary 
condition.  The  face  was  flushed,  expression  anxious,  temperature 
slightly  elevated,  and  pulse  1.30.  Careful  examination  of  the  abdomen 
was  entirely  negative.  After  two  or  three  hours  a  beginning  tenderness 
with  slight  resistance  was  noted  in  the  right  iliac  region.  Operation 
was  decided  upon,  and  performed  without  delay  by  Dr.  Dixon.  There 
was  found  a  perforative  gangrenous  appendix  with  beginning  general 
septic  peritonitis.  The  appendix  was  removed  and  thorough  drainage 
instituted.  The  patient,  however,  died  upon  the  third  day.  This 
case  is  of  interest  in  view  of  the  fact  that  the  fatal  termination 
occurred  not  by  virtue  of  the  pulmonary  involvement,  but  as  the  result 
of  a  perforation  of  the  appendix  which  probably  took  place  simul- 
taneously with  the  very  earliest  symptoms.  Had  there  been  exhibited 
evidence  of  appendiceal  disease  prior  to  the  perforation,  recovery  would 
undoubtedly  have  taken  place  notwithstanding  the  pulmonary  disease. 

Case  VIII. — The  patient,  a  woman,  aged  thirty-three,  with  a  long- 
standing tuberculous  process  in  both  lungs,  experienced  a  sudden  acute 
pain  during  the  night  of  February  13,  1901.  This  was  followed  almost 
immediately  by  a  chill,  and  subsequently  by  vomiting.  She  was  seen 
by  me  on  the  following  morning.  The  temperature  was  but  slightly 
elevated,  the  pulse  was  of  good  quality  and  not  especially  rapid.  The 
pain  in  the  abdomen,  which  was  general  rather  than  localized,  had 
materially  subsided.  Careful  physical  examination  failed  to  disclose 
the  slightest  tenderness  or  resistance  over  the  region  of  the  appendix. 
During  the  next  twenty-four  hours  no  especial  change  was  noted  in 
the  condition.  No  nourishment  was  permitted  by  mouth.  Shortly 
afterward  the  pain  became  more  severe,  and  was  attended  by  renewed 
vomiting  and  a  slight  chill.      The  next  morning  the   physical   exami- 

31 


482  COMPLICATIONS 

nation  remained  completely  negative.  The  expression,  however,  was 
not  so  good  as  on  the  preceding  day.  After  consultation  and  a  con- 
tinued negative  result  of  abdominal,  vaginal,  and  rectal  examination, 
it  was  determined  to  resort  to  exploratory  incision.  The  operation, 
unfortunately,  was  delayed  another  twenty-four  hours,  during  which 
time  the  temperature  roseio  104°  F.,  the  pulse  to  136.  The  abdomen 
had  become  distended,  and  the  whole  picture  was  that  of  septic  peri- 
tonitis. The  operation  was  performed  by  Dr.  Horace  G.  Wetherill. 
On  opening  the  abdomen  free  pus  was  found  throughout  the  gen- 
eral cavity.  The  appendix  was  exceedingly  long,  with  its  tip  dip- 
ping down  over  and  below  the  brim  of  the  pelvis,  where  it  had  become 
adherent,  thus  explaining  the  failure  to  elicit  tenderness  or  rigidity  on 
early  examination.  Perforation  had  taken  place,  and  the  appendix 
was  gangrenous  in  places.  The  patient's  condition  during  the  operation 
was  extremely  desperate.  She  was  taken  from  the  operating-room 
in  collapse,  and  it  was  not  doubted  that  death  would  speedily  ensue. 
During  tlie  next  two  or  three  daj's  the  condition  remained  as  desperate 
as  can  be  imagined.  The  pulse  was  exceedingly  weak,  the  temperature 
considerably  elevated,  and  the  abdomen  greatly  distended.  Fecal 
vomiting  began  on  the  third  day  following  the  operation,  and  the 
patient  became  practically  unconscious.  In  spite  of  vigorous  efforts 
the  bowels  had  not  moved,  and  there  had  been  no  passage  of  gas.  It 
was  evident  that  the  stomach  must  he  relieved  of  the  fecal  matter 
and  the  intestinal  distention  reduced  as  much  as  possible.  While  the 
patient  was  in  a  semicomatose  condition,  the  stomach  was  washed  out 
at  very  short  intervals  with  a  solution  of  soda.  Enormous  quantities 
of  gas  were  removed  at  each  washing,  together  with  considerable  fecal 
matter.  The  lavage  was  continued  in  each  instance  until  the  water 
returned  perfectly  clear.  It  was  remarkable  to  note  the  very  decided 
relief  of  the  abdominal  distention  after  each  washing.  The  improve- 
ment in  the  mental  condition  soon  became  marked.  Stimulation  was 
vigorously  continued,  and  the  lavage  was  repeated  at  short  intervals 
during  the  next  three  days.  Renewed  efforts  to  move  the  bowels  were 
finally  successful,  and  in  the  course  of  a  week  normal  peristalsis  was 
restored.  The  patient  continued  to  exhibit  gratifj'ing  im))ro\ement 
for  a  period  of  nearly  seven  weeks,  when  there  suddenly  de\eloped 
symptoms  of  acute  intestinal  obstruction.  Operation  by  Dr.  Wetherill 
disclosed  very  extensive  intestinal  adhesions,  and  the  patient  survived 
but  a  few  days. 

This  case  is  cited  as  illustrating  the  statement  previously  made  that 
a  genuine  involvement  of  the  appemlix  may  exist  without  any  early 
evidence  of  its  presence  being  elicited  upon  physical  examination.  In 
this  case  the  general  and  constitutional  symptoms  were  sufficiently 
definite  to  characterize  the  attack  as  a  most  serious  abdominal  condition. 
Through  failure  to  tliscover  definite  phj-sical  evidences  of  appendicitis 
there  was  permitted  to  take  place  a  most  disastrous  period  of  delay, 
which  resulted  eventually  in  the  death  of  the  patient.  The  lesson  to  be 
drawn  from  such  an  experience  is  plain  to  the  effect  that,  in  the  presence 
of  such  an  acute  onset,  severe  abdominal  pain,  with  change  in  pulse 
and  temperature,  even  despite  absence  of  rigidity  and  tenderness  over 
the  region  of  the  appendix,  the  only  safe  and  rational  course  would 
have  been  to  perform  an  exploratory  laparotomy.  The  dangers  of 
opening  the  abdomen  in  such  cases  are  comparatively  slight,  while  the 


TUBERCULOSIS    OF    THE    APPENDIX  483 

unfortunate  possibilities  from  delay  are  very  great.  When  in  doubt  early 
in  the  course  of  such  acute  abdominal  affections  it  must  be  recognized 
that  the  best  interests  of  the  patient  are  subserved  by  exposure  to  the 
relatively  slight  dangers  of  abdominal  section,  in  order  to  secure,  first, 
definiteness  of  diagnosis,  and,  secondly,  opportunity  to  invoke  life- 
saving  surgical  aid. 

Case  IX. — The  patient,  aged  fifty  years,  came  to  Colorado  September 
6,  1906,  one  year  after  the  development  of  pulmonary  tuberculosis. 
There  were  great  emaciation  and  physical  debility.  Dyspnea  was 
pronounced  upon  sight  exertion,  and  the  cough  was  frequent  and 
paroxysmal.  The  expectoration,  was  profuse,  the  appetite  poor,  and 
the  sleep  much  disturbed.  Physical  examination  disclosed  extensive 
active  tuberculous  infection  of  the  right  lung  and  slight  involvement  of 
the  left.  No  appreciable  improvement  was  noted  after  several  months' 
residence  in  Colorado.  Early  in  1907  the  patient  developed  an  acute 
appendiceal  attark.  The  initial  ligijr  was  severe,  and  the  pain  in  the 
right  iliac  region  cxcTuciat  ing.  Ininicdiately  after  the  early  vomiting 
the  pulse  became  exccc(li]iu,ly  weak  ami  rapid.  The  patient  was  seen 
in  consultation  by  Dr.  F.  L.  Dixon,  and  much  hesitation,  in  view  of  the 
extreme  physical  debility,  was  felt  as  to  the  expediency  of  operation. 
Despite  the  unfavorable  general  condition,  however,  it  was  decided 
that  the  invalid  was  entitled  to  the  same  operative  procedure  that  would 
be  accorded  a  non-tuberculous  patient.  An  acutely  inflamed  and 
beginning  gangrenous  appendix  embedded  in  a  mass  of  inflamed  and 
gangrenous  omentum  was  removed,  and  the  patient  made  an  unevent- 
ful recovery. 

Dr.  Powers  has  recently  operated  upon  a  tuberculous  patient  of 
Dr.  J.  A.  Wilder  presenting  symptoms  of  acute  fulminating  appen- 
dicitis with  a  history  of  several  former  attacks.  At  the  time  of  the 
previous  illness  it  was  decided  to  resort  to  an  interval  operation  as  soon 
as  practicable.  This  was  subsequently  opposed  by  the  jjatient  and 
family  on  account  of  the  far-advanced  tuberculous  cnmlitidii.  He 
suddenly  experienced  severe  pain,  chill,  and  underwent  iniuicdiate 
collapse.  Under  great  stimulation  the  (i]ieraticiii  was  performed  and 
the  appendix  found  to  have  sloughed  directl\-  oxer  i  lie  wall  of  the  cecum, 
leaving  a  patulous  opening  into  the  intestine  wliich  discharged  its  fecal 
contents  into  the  general  abdominal  cavity.  The  appendix  itself  was 
extensively  gangrenous.  The  abdomen  was  freely  and  cniitimiously 
irrigated  for  many  days  with  the  patient  in  the  Fowler  position.  Itccciv- 
ery  took  place,  and  the  patient  was  permitted  to  resume  the  effort  to 
secure  arrest  from  the  pulmonary  involvement. 

This  case  offers  a  striking  illustration  of  the  wisdom,  in  general,  of 
the  interval  operation  upon  the  pulmonary  invalid,  when  the  history 
of  previous  attacks  establishes  the  diagnosis  of  recurring  appendicitis. 


484  COMPLICATIONS 

CHAPTER   LXIX 
RECTAL  FISTULA 

This  condition  originates  from  abscesses  in  the  connective  tissue 
surrounding  the  lower  portion  of  the  rectum.  It  usually  results  from 
neglect  in  the  treatment  of  simple  anal  abscess  or  in  that  of  a  similar 
pus-collection  in  the  ischiorectal  fossa.  Among  tuberculous  patients, 
however,  a  persisting  indolent  fistula  may  develop  despite  thoroughlj^ 
ef&cient  surgical  treatment  of  the  original  abscess. 

There  are  several  types  of  fistula,  one  of  which  is  the  open  variety, 
with  a  free  communication  to  the  external  skin,  as  well  as  into  the 
intestinal  canal.  Another  is  termed  the  blind  internal  fistula,  in  which 
the  sinus  opens  into  the  bowel  but  has  no  external  outlet.  The  blind 
external  fistula  opens  upon  the  skin,  but  does  not  perforate  the  rectum. 
Irrespective  of  the  type  of  fistula,  the  course  of  the  sinus  in  almo.st 
every  instance  is  tortuous  and  irregular.  The  point  of  internal  perfora- 
tion is  frequentl}'  but  a  short  distance  above  the  anus,  though  in  some 
cases  the  sinus  extends  upward  a  considerable  distance  before  pene- 
trating the  bowel.  The  external  opening  may  be  situated  in  immediate 
proximity  to  the  anus  or  at  a  distance  of  several  inches.  The  discharge 
of  pus  or  liquid  feces  from  the  sinus  produces,  as  a  rule,  considerable 
discomfort  and  irritation.  In  most  eases  there  is  a  comparative  lack 
of  pain  and  tenderness.  The  discharge  varies  according  to  the  nature 
of  the  infection.  When  of  tuberculous  origin,  the  secretion  is  often 
scant  and  watery  in  character.  In  case  of  mixed  infection  it  is  usually 
more  profuse,  of  greater  density,  and  of  a  greenish-yeUow  appearance. 
Tuberculous  fistulse  are  apt  to  e.xhibit  at  the  cutaneous  orifice  a  reddened, 
irregular,  and  overhanging  edge. 

The  method  of  origin  of  small  abscesses  arising  from  the  anal  diver- 
ticula is  closely  analogous  to  appendicitis  with  pus-formation.  Oppor- 
tunity is  aflorded  in  both  conditions  for  the  entrance  of  numerous 
different  microorganisms.  Their  presence,  together  with  the  indefinite 
retention  of  fecal  matter  and  foreign  substances,  gives  rise  to  varying 
degrees  of  irritation  and  inflammatory  change. 

In  reviewing  the  general  etiologj^  of  tuberculous  lesions  of  the 
intestinal  tract  attention  was  called  to  the  mechanic  facilities  offered 
for  the  lodgment  of  tubercle  bacilli  in  the  tiny  lacunae  existing  in  the 
mucous  membrane  above  the  anus.  This  e.xplains  the  distinctly 
tuberculous  origin  of  many  cases  of  rectal  fistula.  While  in  a  consider- 
able number  of  cases  the  fistulous  abscesses  are  in  themselves  tuber- 
culous, a  non-tuberculous  fistula  is  not  infrequent  among  pulmonary 
invalids.  Although  nearly  15  per  cent,  of  all  fistulse  occur  among  this 
class  of  people,  the  local  condition  is  not  invariably  tuberculous. 

The  relation  of  fistula  in  ano  to  pulmonary  tuberculosis  has  been 
the  subject  of  much  uncertainty  and  confusion  for  many  years.  The 
proportion  of  consumptives  afflicted  with  anal  fistula  varies,  according 
to  different  observers,  from  2  to  5  per  cent.  The  condition  has  existed 
in  slightly  over  2  per  cent,  of  the  cases  coming  under  my  personal 
observation.  It  was  even  thought  at  one  time  that  the  existence  of 
fistula  produced  a  degree  of  immunity  to  pulmonary  tuberculosis. 
Among   non-consumptives,   therefore,   it   was   considered   rational   to 


RECTAL    FISTULA  485 

prevent  the  healing  of  the  sinus  for  fear  lest  a  tuberculous  infection  of 
the  lungs  would  subsequently  develop.  If  the  victim  of  the  fistula 
was  a  consumptive,  the  chances  for  recovery  from  the  pulmonary 
disease  were  believed  to  be  enhanced  by  a  continuance  of  the  fistula, 
and  materially  diminished  by  its  closure.  According  to  Freeman, 
it  was  at  one  time  considered  good  treatment  to  produce  artificial 
fistula  in  consumptives  as  a  means  of  cure  of  the  original  disease,  upon 
the  theory  that  injurious  humors  were  thus  drained  from  the  system. 

At  present  there  exist  considerable  differences  of  opinion  as  to  the 
true  relation  of  these  two  affections,  and  especially  as  to  the  applica- 
bility of  remedial  measures  under  varying  conditions.  It  is  well  to 
bear  in  mind,  as  stated,  that  tuberculous  fistulse  may  occur  in  individuals 
presenting  no  other  evidence  of  similar  infection,  and  that  non-tuber- 
culous fistulse  may  sometimes  develop  in  the  midst  of  pulmonary 
phthisis.  In  this  respect  there  is  maintained  a  further  resemblance 
iDetween  abscesses  in  the  appendix  and  in  the  region  of  the  anus.  There 
is,  however,  in  the  two  conditions  a  striking  difference  as  to  the  practical 
construction  to  be  placed  upon  these  relations.  In  connection  with 
appendicitis  it  was  stated  that  a  clinical  distinction  was  unnecessary 
between  tuberculous  appendicitis  and  a  simple  inflammatory  involve- 
ment among  consumptives,  as  the  indications  for  treatment  were  iden- 
tical. The  principles  of  management  as  applied  to  cases  of  rectal  fis- 
tulse, however,  are  not  similarly  uniform,  for  reasons  that  are  perfectly 
obvious.  Appendicitis,  regardless  of  its  origin,  is  recognized  as  a  distinct 
menace  to  life,  without  immediate  operation.  Rectal  fistula,  however, 
at  no  time  threatening  the  life  of  the  individual,  is  embraced  under  an 
entirely  different  category,  the  results  of  surgical  treatment  being  depen- 
dent upon  the  influence  of  the  general  health. 

It  is  important  to  distinguish  between  fistulse  in  themselves  tuber- 
culous without  evidence  of  infection  in  other  parts  of  the  body,  and 
fistulse  in  consumptives  irrespective  of  the  origin.  Among  the  latter 
the  essential  consideration  is  not  the  local  condition  of  possible  tuber- 
culous origin,  but  the  existence  of  an  infection  in  remote  parts,  causing 
a  diminished  resistance  of  the  tissues  and  retarding,  if  not  preventing, 
complete  union  after  operation.  In  this  event  surgical  interference 
may  become  non-effective  and  may  even  react  to  the  disadvantage  of 
the  patient  through  the  refusal  of  the  wound  to  heal,  the  increased  area 
of  broken-down  tissue,  the  occasional  impaired  function  of  the  sphincter, 
and  the  not  infrequent  mental  depression. 

The  decision  as  to  therapeutic  management  must  be  based  upon 
certain  prognostic  considerations  which  relate  directly  to  the  extent 
of  pulmonary  tuberculosis  and  the  general  vitality.  Tuberculous 
fistulse  in  otherwise  healthy  individuals  are  subject  to  the  same  prin- 
ciples of  radical  surgical  management  as  simple  fistulse  among  the 
same  class  of  patients.  In  consumptives  the  special  indications  for  the 
operation  relate  to  the  supposed  ability  of  the  tissues  to  heal  promptly 
after  thorough  excision.  Surgical  interference  among  pulmonary 
invalids  as  a  class  has  fallen  into  considerable  disrepute  because  of  the 
frequent  unsatisfactory  results  of  the  operation.  It  must  be  admitted 
that  among  these  patients  it  is  notoriously  unsuccessful  in  a  large 
proportion  of  cases.  It  is  well  known  that  the  course  of  the  pulmonary 
disease  is  not  influenced  either  for  better  or  worse  by  the  complicating 
fistula,   save  for  the  unfavorable  results  sometimes  noted  after  ill- 


COMPLICATIONS 


considered  and  untimely  surgical  procedures.  The  alleged  development 
of  pulmonary  tuberculosis  following  operation  for  rectal  fistula  is  prob- 
ably explained  by  the  previous  latency  of  the  pulmonary  infection  ami 
its  delayed  clinical  recognition.  On  the  other  hand,  the  influence  of 
advanced  pulmonary  phthisis  upon  the  local  fistulous  condition  is 
beyond  question. 

The  unfortunate  results  of  operation  upon  consumptives  are  fre- 
quently traceable  to  the  lack  of  proper  discrimination  exercised  as  to 
the  selection  of  cases.  The  operation  is  often  performed  upon  invalids 
with  advanced  pulmonary  disease,  or  at  a  time  when  the  infection, 
though  of  recent  developnient,  is  associated  with  greatly  impaired  nutri- 
tion and  lessened  individual  resistance.  The  essential  consideration  as 
to  the  propriety  of  the  operation  attaches  not  to  the  extent  or  duration 
of  the  tuberculous  change  in  the  lung,  but  rather  to  its  comparatively 
slight  activitij  and  the  existence  of  an  excellent  nutrition  as  indicative  of 
general  vitality.  It  is  my  custom  to  deny  this  operation  to  patients 
until  the  pulmonary  infection  has  undergone  almost  if  not  complete 
arrest,  with  the  restoration  of  at  least  a  normal  body  weight.  Until 
such  time  patients  are  quieted  with  the  assurance  that  the  persisting 
fistula  exercises  no  possible  influence  upon  the  disease,  and  that  a 
fortunate  result  of  operation  is  permitted  only  by  an  increased  general 
resistance.  A  significant  commentary  as  to  the  frequency  of  ill-advised 
operation  is  the  fact,  that  in  nearly  every  instance  of  rectal  fistulse 
among  pulmonary  invalids  at  the  time  of  coming  under  my  observation 
an  operation  had  previously  been  performed  with  unsatisfactory  result. 

The  surgical  management,  aside  from  ordinary  drainage  operations 
which  are  indicated  in  all  cases  of  abscess  formation  in  this  vicinity, 
consists  of  simple  incision  with  curetment,  or  of  total  extirpation  of  the 
fistulous  tract.  Incision  is  the  less  formidable  and  more  usual  method  of 
procedure,  and  is  sometimes  attended  by  satisfactory  results.  In 
case  of  a  complete  open  fistula  a  grooved  director  is  passed  from  the 
external  opening  into  the  rectum,  and  the  intervening  tissues  divided 
with  a  sharp  curved  bistoury.  This  is  preceded  by  thorough  stretching 
of  the  sphincter.  If  the  fistula  is  incomplete,  a  connection  must  be 
established  from  the  skin  to  the  interior  of  the  bowel  by  the  director. 
After  the  entire  sinus  has  been  laid  open,  the  infected  area  is  forcibly 
scraped  and  sterilized  with  pure  phenol.  The  wound  is  packed  with 
iodoform  gauze,  the  healing  taking  place  by  granulation. 

The  process  of  excision,  which  is  more  likely  to  be  attended  by  a 
speedy  and  gratifying  result  among  tuberculous  cases,  consists  of  the 
dissection  of  the  entire  fistulous  canal.  Great  care  must  be  taken  to 
remove,  if  possible,  a  considerable  area  of  apparently  non-infected  tissue. 
This  procedure  is  even  advisable  in  chronic  cases  exhibiting  dense 
fibrous  tissue  formation  along  the  wall  of  the  sinus.  After  cleansing 
and  sterilization,  the  wound  is  closed  with  silkworm-gut  sutures  in  an 
effort  to  secure  accurate  coaptation  of  the  walls.  Especial  care  should 
be  taken  to  bring  the  parts  in  perfect  apposition  at  the  anal  end  of  the 
sinus.  For  this  purpose  the  ends  of  the  sphincter  muscle  should  be 
united  by  a  suture  encircling  and  passing  through  the  muscle.  Primary 
union  takes  place  in  a  large  proportion  of  cases.  If  asepsis  is  imperfect 
and  suppuration  ensues,  the  stitches  should  be  immediately  i-emoved 
and  the  reopened  wound  packed  with  gauze,  thus  permitting  healing 
to  take  place  by  granulation. 


GENERAL    ETIOLOGIC    CONSIDERATIONS 

SECTION   VII 
Tuberculosis  of  the  Genito-urinary  Tract 


CHAPTER   LXX 
GENERAL  ETIOLOGIC  CONSIDERATIONS 

Tuberculous  infection  of  either  tlie  genital  or  urinary  system  is 
almost  always  secondary  to  a  preexisting  focus  in  some  other  portion 
of  the  body.  It  is  difficult,  however,  to  deny  absolutely  the  possible 
existence  of  primary  tuberculosis  in  these  parts.  Isolated  cases  of 
such  an  infection  are  found  in  the  literature  of  the  subject,  but  the 
evidence  is  frequently  insufficient  to  sustain  the  assertion  that  the 
reported  condition  is  one  of  genuine  primary  infection  of  the  genito- 
urinary system.  The  term  ■primary  is  often  used  in  connection  with 
tuberculosis  of  this  region,  not  as  denoting  the  initial  site  of  infection 
of  the  entire  organism,  but  rather  as  indicating  a  priority  of  involve- 
ment in  a  given  portion  of  the  genito-urinary  system  in  comparison 
with  infection  of  neighboring  parts.  In  discussing  the  general  etiology 
of  tuberculous  infection  of  the  genito-urinary  tract,  the  word  primari/ 
will  be  used  simply  in  the  sense  of  its  local  application,  it  being  well 
understood  that  the  infection  must  proceed  in  all  cases  from  some 
antecedent,  though  often  undiscoverable,  focus. 

The  primary  origin  of  tuberculous  lesions  in  these  regions  and  the  sub- 
sequent sequence  of  infection  have  been  the  subject  of  much  investiga- 
tion. In  the  past  decided  differences  of  opinion  have  been  entertained 
as  a  result  of  clinical  and  pathologic  research.  Following  much 
experimental  study  in  recent  years,  there  is  a  greater  unanimity  of 
medical  opinion  as  to  the  preponderating  sites  of  infection  and  the 
more  common  direction  of  further  dissemination.  The  parts  most 
frequently  involved  are  the  kidney,  Fallopian  tubes,  epididymis,  and 
prostate.  It  is  known  that  the  tuberculous  process  may  be  primary 
in  any  of  these  organs.  From  a  clinical  or  surgical  standpoint  it  is  fair 
to  assume  that  the  so-called  primary  origin  of  the  disease  occurs  with 
almost  equal  frequency  in  the  kidne>-,  ppiili(l\iiiis,  and  Fallopian  tubes, 
with  the  prostate  gland  less  coiiiiii(iiil\-  the  seat  of  early  infection. 
Research  work  now  being  conducted  at  tlic  I'hipps  Institute  in  connection 
with  renal  tuberculosis  forces  the  conclusion,  however,  that  the  kidney 
is  by  far  the  more  frequent  site  of  infection.  The  urine  of  60  patients 
with  pulmonary  consumption  was  exhaustively  examined  for  the 
recognition  of  tubercle  bacilli.  After  eliminating  all  possibility  of  error 
resulting  from  the  possible  confusion  of  the  bacilli  with  other  micro- 
organisms, it  was  found  that  the  examination  in  44  instances  was 
attended  by  a  positive  result.  This  work  was  of  importance  in  showing 
that  tubercle  bacilli  were  being  excreted  with  the  urine  of  phthisical 
patients  to  a  much  greater  extent  than  had  been  generally  supposed. 
The  result  was  susceptible  of  a  double  interpretation — first,  that  the 
bacilli  had  been  filtered  from  the  blood  through  the  glomeruli  without 


COMPLICATIONS 


local  lesion  along  the  urinary  tract,  and,  secondly,  that  genuine  tuber- 
culous lesions  existed  either  in  the  kidney  or  along  the  downward 
course  of  the  urinary  system. 

Heiberg  and  Morris  report  tuberculosis  of  the  kidney  to  be  found  at 
autopsy  in  only  2  per  cent,  of  the  cases  of  pulmonary  tuberculosis. 
Hamilton  has  shown  that  after  the  bacilli  gain  entrance  to  the  circulation, 
they  may  be  found  in  the  glomeruli  of  the  kidney,  within  the  afferent 
arteries,  in  the  interstitial  tissue,  and  in  the  uriniferous  tubules.  Wal- 
sham,  in  his  study  of  excretion  tuberculosis,  has  demonstrated  the 
presence  of  bacilli  in  the  glomeruli  without  evidence  of  change  in  the 
surrounding  tissues  or  in  the  vessels  of  the  glomerulus.  He  has  proved 
that  the  bacilli  may  become  arrested  at  some  point  in  the  uriniferous 
tubes,  often  in  the  medulla  of  the  kidney,  and  produce  secondary  foci  of 
tuberculous  infection.  His  views  as  to  the  epithelial  spread  of  the 
infection  in  the  kidney  are  indorsed  by  Benda,  who  calls  attention  to 
the  presence  of  bacilli  en  masse  in  the  midst  of  the  epithelial  constituents 
of  the  kidney  in  the  common,  straight,  and  convoluted  tubules.  He 
emphasizes  the  extension  of  tubercle  deposit  from  the  straight  and 
common  uriniferous  tubes  in  explanation  of  the  origin  of  renal  tuber- 
culosis in  the  medullary  substance,  but  ascribes  the  infrequency  of  dis- 
semination from  the  convoluted  tubes  in  the  cortex  to  the  plugging 
incident  to  the  tuberculous  processes.  Apropos  of  Walsham's  study 
the  further  investigations  at  the  Phipps  Institute  under  the  supervision 
of  Walsh  are  of  special  interest.  Sixty  autopsies  were  performed  upon 
tuberculous  subjects,  and  the  Ixidiicys  in  each  instance  were  cut  into 
very  small  pieces  and  subjcitcd  t^  careful  macroscopic  and  histologic 
examination.  Definitely  typi.-al  lulici'cles  were  found  in  35  cases. 
In  addition,  the  condition  in  (iilin-  laiscs  closely  resembled  a  tuberculous 
invasion  of  the  kidney,  an  :i»uiii]i;i(iu  as  to  its  probable  character 
being  justified  by  the  presence  nt  miliary  tubercles  in  other  organs. 
If  the  latter  instances  be  included,  a  tubercle  deposit  was  found  in  63 
per  cent,  of  the  cases.  Out  of  37  cases  examined  by  Hein,  tubercles 
were  found  in  21  instances,  or  about  57  per  cent.  In  the  light  of  such 
pathologic  data  it  must  be  accepted  that  tuberculosis  of  the  kidney 
exists  in  approximately  one-half  of  the  cases  of  pulmonary  tuberculosis, 
and  to  a  greater  extent  than  in  any  other  portion  of  the  genito-urinary 
system.  These  results  are  in  striking  contrast  to  Senn's  recent  estimate 
that  one  out  of  every  18  consumptives  exhibits  a  tuberculous  process  in 
some  portion  of  the  genito-urinary  sj'stem.  The  pathologic  institute 
at  Prague  has  reported  but  5.6  per  cent,  of  renal  tuberculosis  recognized 
at  autopsy  upon  adult  consumptives,  while  Rilliet  and  Barthez  report 
15.7  per  cent,  among  children. 

It  is  probable  that  the  frequency  of  ]iriinar>-  involvement  of  the 
epididymis  corresponds  fairly  closely  to  that  nf  tlie  Fallopian  tubes. 
As  a  result  of  tuberculous  infection  of  the  epidiil) mis  an  extension  of 
the  process  may  take  place  to  the  seminal  vesicles,  prostate,  and  some- 
times to  the  bladder.  From  the  Fallopian  tubes  the  infection  may  be 
disseminated  to  the  ovary,  uterus,  and  peritoneum. 

Priniary  tuberculosis  of  the  bladder  is  exceedingly  rare.  Its  second- 
ary involvement  may  proceed  from  a  downward  infection  originating 
in  the  kidney,  or  from  an  upward  distribution  emanating  from  the 
prostate  or  male  genital  organs.  It  is  doubtful  if  upward  extension  of 
the  tuberculous    infection  may  take  place  from  the  bladder  to  the 


GENERAL    ETIOLOGIC    CONSIDERATIONS  489 

kidney.  Giani  has  concluded,  as  a  result  of  his  own  experimental 
research,  that  ascending  tuberculous  infection  to  the  kidney  is  absolutely 
impossible  against  a  normal  downward  current  of  urine.  The  mode 
and  direction  of  tuberculous  infection  involving  both  the  genital  and 
urinary  systems,  with  the  bladtler  as  more  or  less  a  neutral  point,  were 
formerly  a  greater  bone  of  contention  than  at  present.  Cornet  believes 
urogenital  tuberculosis  to  be  almost  always  ascending  in  character,  its 
origin  in  most  cases  being  traceable  to  the  genitals.  He,  therefore, 
regards  tuberculosis  of  the  urinary  apparatus  as  generally  secondary 
to  that  of  the  genital  system,  and  states  that  "this  conception  is  almost 
universally  adopted."  He  bases  his  conclusions  upon  his  clinical 
experience  with  individual  cases  and  upon  the  greater  relative  fre- 
quency of  genital  than  of  urinary  tuberculosis,  as  shown  by  the  autopsy 
reports  of  several  foreign  observers. 

It  is  important  to  call  attention  to  the  fact  that  statistical  reports 
concerning  the  relative  frequency  of  tuberculous  lesions  in  various  parts 
of  the  genito-urinary  system,  are  in  themselves  of  little  value  as  con- 
stituting a  basis  for  conclusions  concerning  the  primary  seat  of  the 
disease  and  the  method  and  direction  of  extension.  It  is  even  impossible 
to  differentiate  with  accuracy  the  priority  of  the  various  tuberculous 
deposits  by  a  comparison  of  their  stages  of  development.  It  should 
be  remembered  that  the  age  of  lesions  per  se  in  any  part  of  the  body 
is  not  a  determining  factor  in  the  degree  of  their  development. 

Cornet  explains  the  ascent  of  the  bacilli  to  the  kidneys  partly  by 
extension  along  the  surface  of  the  ureters,  partly  through  the  lymph- 
channels  of  the  mucous  membrane,  and  to  some  extent  by  regurgitation 
of  infected  urine.  He  opposes  the  theory  of  downward  extension  from 
the  kidneys  to  the  bladder  upon  the  basis  of  the  washing  process  incident 
to  the  flow  of  the  urine.  He  cites  numerous  cases  reported  by  observers 
in  substantiation  of  his  theory  regarding  primary  involvement  of  the 
genital  organs,  and  the  subsequent  ascending  infection.  He  regards 
the  prostate  as  the  most  important  site  of  the  primary  process  in  the 
male,  and  the  Fallopian  tubes  in  the  female.  He  describes  at  length 
the  numerous  possibilities  of  exogenous  infection,  and  explains  the 
relative  infrequency  of  tuberculous  lesions  upon  the  external  genitals 
by  the  supposedly  analogous  penetrability  of  the  mucous  channels  by 
the  gonococci.  In  support  of  his  theories  he  describes  with  much 
circumstance  the  opportunities  for  the  development  of  genital  tubercu- 
losis either  through  auto-infection  or  otherwise.  Even  were  other 
clinical  and  pathologic  facts  not  distinctly  antagonistic  to  this  view, 
it  would  still  appear  difficult  to  reconcile  such  an  opinion  to  the  not 
infrequent  development  of  genito-urinary  tuberculosis  among  children. 
Numerous  instances  have  been  reported  of  this  infection  niiiDiis  the  \'ery 
young.  Morse  has  recently  cited  a  case  of  tuberculosis  of  I  he  l^i(hiey 
in  an  infant  of  six  months,  the  bacilli  being  demonstrated  in  the  urine 
microscopically,  culturally,  and  by  animal  inoculations.  It  certainly 
involves  a  vivid  stretch  of  the  imagination  to  explain  any  considerable 
number  of  instances  of  genito-urinary  tuberculosis  among  the  very 
young  upon  the  fancied  theory  of  infected  towels.  Baumgarten  has 
endeavored  to  show  by  experiments  upon  animals  that  the  course  of 
the  tuberculous  infection  follows  the  flow  of  the  secretions,  the  direction 
extending  doivnward  from  the  kidneys  to  the  bladder  and  upward  from 
the  testicle  toward  the  prostate.     The  consensus  of  modern  opinion, 


490  COMPLICATIONS 

however,  based  upon  the  results  of  exhaustive  studj-,  points  to  the 
principal  mode  of  infection  as  emanating  from  the  circulation. 

Ascending  infection  in  some  portions  of  the  genito-urinary  tract 
is  not  to  be  denied  in  occasional  instances.  There  undoubtedly  occurs 
an  upward  extension  from  the  epididymis  to  the  testes,  and  from  the 
prostate  to  the  bladder.  The  involvement  of  the  kidney,  however, 
may  usually  be  regarded  as  primary  and  filtrative  from  the  blood. 
Inability  to  demonstrate  the  presence  of  bacilli  in  the  blood  in  such 
cases,  affords  no  valid  argument  against  this  method  of  infection,  as 
it  is  well  known  that  even  in  acute  miliary  tuberculosis  with  abundant 
tubercle  formation  in  the  kidney,  blood  examinations  have  been  repeat- 
edly negative  in  character.  It  is  worthy  of  note  that  tuberculosis  of 
the  kidney  in  women,  among  whom  there  is  no  opportunity  for  upward 
extension  to  this  organ  from  the  genital  tract,  is  found  at  autopsy  nearly 
twice  as  often  as  in  the  male  sex.  The  infection  may  sometimes 
take  place  through  the  capsule  of  the  kidney,  as  a  result  of  direct  exten- 
sion from  a  neighboring  tuberculous  process.  It  may  be  assumed  that 
in  a  few  isolated  cases  of  renal  tuberculosis  trauma  has  caused  the 
development  of  active  manifestations  among  patients  in  whom  the 
condition  had  previousl}'  been  latent. 


CHAPTER   LXXI 

TUBERCULOSIS  OF  THE  KIDNEY 

The  chief  clinical  interest  attaching  to  tuberculosis  of  the  genito- 
urinaiy  system  relates  to  the  involvement  of  the  kidney.  Tuberculous 
infection  of  this  organ  is  exceedingly  common  among  pulmonary  invalids, 
as  shown  by  the  statistical  data,  to  which  allusion  has  been  made  in 
the  previous  chapter.  Autopsy  iil>s,  r\  jtinns  indicate  that  the  con- 
dition is  bilateral  in  from  50  to  (iii  |  '  r  n m.  if  the  cases.  Bevan  has 
referred  to  the  report  of  12,732  autMp~ii~  n  Kiel.  Among  the  cases  of 
renal  tuberculosis,  62. .3  per  cent,  were  bilateral  and  37.6  per  cent, 
unilateral.  These  results  are  in  .striking  contrast  to  the  infrequency 
of  bilateral  involvement  as  observed  at  the  operating  table.  Upon  the 
basis  of  the  clinical  evidence  alone  renal  tuberculosis  is  Ijilateral  in  not 
over  15  per  cent,  of  the  cases.  Israel  found  over  90  per  cent,  unilateral, 
as  did  Facklan.  Kiimmel  reported  8S  per  cent,  unilateral  and  Kron- 
lein,  92  per  cent.  Rovsing  reported  a  unilateral  infection  in  216  out 
of  350  cases.  These  results  strongly  suggest  an  involvement  limited 
to  a  single  kidney  in  cases  of  initial  renal  tuberculosis.  The  necessity 
of  an  early  recognition  of  the  condition  is  thus  apparent,  as  well  as 
the  wisdom  of  more  prompt  recourse  to  surgical  interference.  It  must 
be  remembered,  however,  that  such  evidence  is  entireh^  of  a  clinical 
nature,  and  that,  in  fact,  the  condition  is  bilateral  much  oftener  than 
is  indicated  by  the  general  symptomatology  or  the  results  of  clinical 
examination.  In  view  of  the  histologic  studies  of  Walsh  as  to  the 
frequency  of  tubercle  deposit  in  the  kidneys  of  consumptives,  it  is 
apparent  that  the  diagnostic  evidences  of  tuberculous  infection  are 


TUBERCULOSIS    OF    THE    KIDNEY  491 

often  absent.  The  clinical  data  alone  might  seem  to  establish  merely 
a  unilateral  involvement.  An  assumption  as  to  the  non-limitation  of 
the  disease  to  a  single  kidney  must  not  be  construed,  however,  as  an 
argument  against  the  rationale  of  radical  surgical  measures  directed 
to  the  seat  of  the  recognized  involvement. 

Pathology. — The  primary  pathologic  condition  is  the  deposit  of 
numerous  tubercles  in  the  kidney.  These  are  at  first  discrete,  but 
subsequently  exhibit  a  rapid  coalescence.  In  acute  miliary  tuberculosis 
the  tubercles  are  found  chiefly  in  the  cortex,  and  occur  merely  as  a  part 
of  a  general  miliary  involvement  of  other  organs.  It  has  been  questioned 
if  the  miliary  nodules  of  the  kidney  proceed  to  genuine  caseation  liefore 
the  death  of  the  patient.  The  evidence  from  numerous  pathologists 
is  to  the  effect  that  cascatidn  t:ikos  place  extremely  early  in  these  cases, 
and  that  this  cuiidition  is  IrcMnicntly  observed  at  autopsy  among  patients 
succumbing  to  acute  iniHary  tul)erculosis.  This  is  particularly  true 
of  the  tuberculous  nodules  in  the  cortical  substance  of  the  kidney,  and 
especially  as  they  approach  the  surface,  in  contrast  to  the  tubercle 
deposit  in  the  medulla.  The  nodules  of  the  cortex  are  almost  uniformly 
of  small  size,  comparable  to  that  of  the  millet-seed,  but  may  sometimes 
attain  the  dimensions  of  a  large  pea.  Hamilton  calls  attention  to  a 
change  in  the  shape  of  the  nodules  according  to  their  locality,  being 
wedge  shaped  upon  the  surface  of  the  cortex,  more  rounded  within  the 
cortical  substance,  and  fusiform  within  the  medulla.  He  asserts  that 
caseation  takes  place  as  soon  as  the  nodule  is  sufficiently  large  to  permit 
macroscopic  recognition.  In  the  non-miliary  form  small  tuberculous 
nodules  may  arise  from  within  a  tiny  blood-vessel  in  the  cortical  sub- 
stance, or  within  one  of  the  uriniferous  tubules.  In  the  former  instance 
the  infection  is  clearly  hematogenous  in  origin,  and  in  the  latter,  excre- 
tory. In  either  event,  whether  the  center  of  the  primary  focus  be 
situated  within  a  blood-vessel,  in  the  cortex,  or  within  a  urinferous 
tube,  extension  and  coalescence  of  adjacent  tubercles  ra])i(lly  take  place. 
Caseation  and  softening  supervene,  and  the  parenchyma  nf  I  lie  kidney 
becomes  broken  down  into  cavities  filled  with  pus  and  debris.  As  a 
result  of  the  abscess  formation  and  necrosis,  the  entire  kidney  is  some- 
times transformed  into  a  single  pouch  of  broken-down  tissue,  or  there 
may  be  multiple  discrete  abscesses  with  well-defined  septa.  Nodules 
may  appear  upon  the  kidney  surface,  and  produce  an  infection  of  adja- 
cent structures.  The  process  may  extend  peripherally  through  the 
capsule  of  the  kidney  and  result  in  the  formation  of  perinephritic 
abscesses.  The  infection  may  travel  downward,  eausin,;;  u  tubeiculous 
involvement  of  the  ureters  and  bladder.  The  walls  of  the  ureter-  may 
become  thickened  throughout  the  entire  course,  and  ulceiatidus  ilexclop 
upon  the  mucous  surface.  Stenosis  of  the  ureter  may  be  iiiciduced  by 
the  occlusive  effect  of  the  inflammatory  thickeiiinp,,  in  conjunction 
with  the  presence  of  debris.  This  may  result  in  the  retention  of  urine 
and  dilatation  of  the  pelvis,  with  enlargement  of  the  kidney.  A  clinical 
fact  of  considerable  importance  in  connection  with  a  tuberculous  process 
in  one  kidney  is  the  development  of  non-tuberculous  irritative  and 
degenerative  changes  in  the  kidney  of  the  opposite  side.  I  have  recently 
seen  this  occurrence  in  two  conspicuous  cases,  in  both  of  which  the 
second  kidney  was  apparently  non-tuberculous,  but  exhibited  evidence 
of  nephritic  degeneration  to  such  an  extent  as  to  contraindicate,  in 
the  minds  of  surgeons,  a  nephrectomy  upon  the  tuberculous  kidney  of 


492  COMPLICATIONS 

the  other  side.  In  general,  however,  the  existence  of  an  irritative  or 
even  degenerative  condition  in  the  second  kidney  should  not  preclude 
the  prompt  performance  of  nephrectomy  upon  the  genuinely  tuberculous 
organ,  for  the  reason  that  excision  of  the  tuberculous  focus  often  removes 
the  source  of  secondary  infection. 

Sjrmptoms. — The  symptoms  of  renal  tuberculosis  are  usually  of 
insidious  onset,  entailing  in  many  cases  an  advanced  tuberculous 
process  before  recognition  of  the  condition.  Extensive  destructive 
change  limited  to  one  kidney  may  take  place  without  the  exhibition  of 
any  clinical  symptoms  whatsoever.  This  is  more  likely  to  be  the  case 
wlien  the  bladder  has  not  become  secondarily  affected,  and  when  the 
tuberculous  process  does  not  involve  the  pelvis  or  renal  tubes.  In 
cases  unattended  by  bladder  infection,  the  symptoms  of  the  kidney 
involvement  may  be  altogether  absent  for  prolonged  periods.  An 
occasional  complete  obliteration  of  one  ureter  may  prevent  a  recognition 
of  characteristic  changes  in  the  urine. 

The  ordinary  symptoms  of  renal  tuberculosis  consist  of  increased 
frequency  of  urination,  change  in  the  character  of  the  urine,  pain  and 
tenderness  in  the  region  of  the  kidney,  with  possibly  attacks  of  renal 
colic,  enlargement  of  kidney,  and  the  coexistence  of  slowly  progressive 
constitutional  symptoms. 

Frequent  jnicturition  often  occurs,  long  before  the  recognition  of 
pus,  blood,  albumin,  renal  casts,  or  tubercle  bacilli  in  the  urine.  The 
earliest  clinical  feature  may  consist  of  simple  polyuria,  or  there  may  be 
associated  symptoms  of  more  or  less  bladder  irritation.  The  desire 
to  urinate  recurs  at  short  intervals  during  the  night,  as  well  as  by  day, 
and  is  often  attended  by  varying  degrees  of  pain  and  tenesmus. 

A  characteristic  change  in  the  appearance  of  the  urine  is  sometimes 
the  first  symptom  to  attract  the  attention  of  the  individual.  The  urine 
may  be  cloudy,  smok^•,  or  distinctly  opaque,  .somewhat  resembling 
diluted  milk,  though  in  the  latter  ca.se  the  color  is  apt  to  be  rather 
yellow.  The  cloudy  or  the  smoky  effect  is  produced  by  the  presence  of 
small  quantities  of  pus  or  blood  respectively.  A  mixed  infection 
occasionally  supervenes,  the  bacilluria  often  being  clue  to  the  presence 
of  the  staphylococcus  or  the  colon  bacillus.  I  have  under  observation 
at  the  present  time  an  exceedingly  interesting  ca.se  of  colon  bacillus 
infection  which  will  be  described  in  connection  with  the  clinical  appli- 
cation of  the  bacterial  vaccines.  Botli  the  pus  and  blood  may  vary 
greatly  in  amount,  in  some  instances  being  recognized  only  by  micro- 
scopic examination.  In  other  cases  there  is  iiii|iait(>d  a  distinct  change 
to  the  gross  appearance  of  the  urine.  Ilcini'iiliam-;  sometimes  suffice 
to  occlude  the  ureter  and  produce  intense  pain,  with  other  associated 
symptoms  of  renal  colic.  In  some  cases  a  sudden  hematuria  may  be 
the  first  symptom  referable  to  the  condition.  The  microscopic  exami- 
nation of  the  urine  easily  establishes  the  presence  or  absence  of  pyuria, 
hematuria,  or  bacilluria.  Considerable  difficulty  is  usually  encountered 
in  the  microscopic  search  for  tubercle  bacilli  in  the  urine,  but  exhaustive 
examinations  with  perfected  technic  will  demonstrate  their  presence 
in  a  very  considerable  number  of  cases.  The  smegma  Ijacillus  may  be 
differentiated  by  the  use  of  alcohol,  as  explained  in  the  opening  chapter. 
Pain  may  be  so  slight  as  to  attract  little  attention,  and  at  other 
times  become  an  exceedingly  prominent  symptom.  The  pain  may  con- 
sist merely  of  discomfort  and  uneasiness  in  the  lumbar  region,  or  it  may 


TUBERCULOSIS    OF    THE    KIDNEY  493 

extend  downward  in  the  direction  of  Poupart's  ligament.  In  the  latter 
event  it  is  usually  more  severe  and  is  often  accompanied  by  nausea  and 
vomiting.  These  symptoms,  in  connection  with  intense  lumbar  pain 
radiating  to  the  bladder,  are  characteristic  of  the  passage  of  blood, 
necrotic  tissue,  or  debris  through  the  ureter.  The  pain  in  this  locality 
does  not  always  partake  of  an  acute  nature,  but  may  appear  as  a  dull, 
grinding  ache  or  a  sense  of  ill-defined  soreness.  With  the  development 
of  perinephritic  abscesses  the  pain  and  tenderness  are  confined  to  the 
region  of  the  kidney  in  the  costovertebral  angle,  and  are  accompanied 
by  other  manifestations  suggestive  of  abscess  formation,  consisting  of 
temperature  elevations,  chills,  and  tumor  in  the  renal  region. 

In  coincident  vesical  involvement  the  symptoms  relate  to  frequent 
micturition,  tenesmus,  and  pain  emanating  from  the  neck  of  the  blad- 
der and  referred  to  the  perineum.  These  are  aggravated  upon  exer- 
tion, particularly  walking,  riding,  or  jarring  of  the  body,  and  are  more 
pronounced  in  the  sitting  than  in  the  recumbent  position.  Several 
of  my  patients  have  complained  that  the  pain  is  considerably  more 
intense  during  the  cold  weather  and  whenever  the  surface  of  the  body 
has  become  chilled  to  any  extent. 

An  enlargement  of  the  kidney  is  sometimes  recognized  upon  palpa- 
tion, but  this  is  by  no  means  constant.  Furthermore,  an  increased  size 
of  one  kidney,  in  the  presence  of  other  clinical  manifestations  of  renal 
tuberculosis,  does  not  always  afford  in  itself  positive  evidence  as  to  the 
organ  involved,  as  will  be  explained  presently. 

Considerable  importance  attaches  to  the  condition  of  the  general 
health.  There  is  frequently  a  slight  elevation  of  temperature,  with  loss 
of  appetite  and  general  indisposition,  together  with  more  or  less  nervous 
disturbance  as  a  cumulative  result  of  the  continued  bladder  irritation. 
A  certain  peevishness  and  irritability  of  temperament  are  noted.  Sleep 
is  much  disturbed,  and  nutrition  suffers  to  a  moderate  extent.  Often 
tuberculous  lesions  in  other  parts  of  the  body  may  be  recognized  upon 
careful  examination. 

The  diagnosis  of  renal  tuberculosis  rests  upon  the  previous  history, 
the  exhibition  of  symptoms  just  described,  the  results  of  physical  exami- 
nation, the  cUscovery  of  tubercle  bacilli  in  the  urine,  the  cystoscopic 
examination  of  the  bladder,  x-ray  differentiation,  the  segregation  of  urine 
or  catheterization  of  ureters,  and  an  investigation  of  the  excretory  capa- 
city. 

The  previous  histoiy  is  of  value  in  yielding  possible  data  concerning 
antecedent  tuberculous  processes  in  other  parts  of  the  body. 

Physical  examination  often  furnishes  positive  information  regarding 
tuberculous  deposits  in  the  lungs,  glands,  bones,  joints,  serous  mem- 
branes, epididymis,  or  prostate. 

It  should  be  borne  in  mind  that  too  much  dependence  should  not  be 
placed  upon  the  symptoms  per  se,  as  other  conditions,  especially  stone 
in  the  pelvis  of  the  kidney,  may  closely  simulate  the  clinical  picture 
of  renal  tuberculosis.  Again,  the  tuberculous  character  of  the  affection 
having  been  definitely  established  by  urinary  examination,  a  decision 
from  the  symptoms  alone  as  to  which  kidney  is  diseased  is  not  always 
devoid  of  difficulty.  The  likelihood  of  confusion  relates  to  a  possible 
exaggeration  of  the  significance  of  pain  and  of  enlargement.  Kelly 
calls  attention  to  the  pos.sibility  of  pain  upon  the  unaffected  side,  and 
Meyer  recites  a  case  in  point  coming  under  his  observation,  the  correct 


494  COMPLICATIONS 

selection  of  the  kidney  suitable  for  operation  being  made  upon  the  basis 
of  the  cystoscopic  findings,  although  complaint  was  constantly  made  of 
pain  upon  the  opposite  side.  In  the  same  way.  even  with  urinary  evi- 
dence of  renal  involvement,  a  non-tuberculous  kidney  considerably 
hypertrophied  may  become  very  misleading. 

There  is  no  definite  relation  between  a  demonstration  of  tiibercle 
bacilli  in  the  urine  and  a  genuine  renal  involvement,  as  it  has  been 
shown  that  bacilli  may  be  found  in  the  urine  of  a  considerable  number 
of  advanced  pulmonaiy  invalids  without  actual  pathologic  evidence  of 
renal  tuberculosis.  In  many  cases  they  find  their  way,  as  pre\iou.sly 
stated,  into  the  uriniferous  tubules  from  the  glomeruli  without  visible 
structural  change.  In  some  ca-ses  tubercle  bacilli  are  eliminated  with 
the  urine  from  an  infected  bladder,  which  is  known  to  be  a  frequent 
seat  of  secondary  involvement.  In  case  of  a  previous  ascencUng  infec- 
tion from  the  prostate  to  the  bladder,  or  from  the  epicUdymis  to  the 
prostate,  the  bacilli  may  contaminate  the  flow  of  urine  despite  absence  of 
kidney  disease.  On  the  other  hand,  bacilli  may  be  present  in  the  urine 
as  a  result  of  actual  tuberculous  lesions  of  the  renal  tissues  without  the 
exhibition  of  clinical  symptoms.  Slight  tuberculous  processes  in  the 
kidney  are  occasionally  subject  to  complete  fibrous  repair,  and  are 
unattended  by  further  caseation  or  necrotic  change.  The  recognition 
of  bacilli,  therefore,  is  insufficient  to  afford  any  accurate  criterion 
by  which  to  judge  of  the  existence  and  degree  of  renal  disease.  The 
bacilli  are  of  especial  import  in  connection  with  accompanying  symp- 
toms and  other  methods  of  clinical  diagnosis.  It  is  essential  to  recognize 
a  distinction  between  the  significance  of  the  laboratory  finthngs  and  the 
other  clinical  evidences  of  kidney  tuberculosis.  In  other  words,  the 
acceptance  of  an  immediate  surgical  aspect  of  the  condition  should  not 
be  based  alone  upon  the  presence  of  bacilli  in  the  urine. 

Occasionally,  the  characteristic  .'jymptoms  of  advanced  tuberculosis 
of  this  organ  may  exist  without  an  early  microscopic  demonstration  of 
the  bacilli.  Negative  examinations,  however,  are  less  frequent  than 
formerl}-,  on  account  of  the  more  careful  and  elaborate  technic  employed 
at  the  present  time.  Failure  to  discover  the  microorganisms  upon  urin- 
ary examination  in  cases  of  renal  tuberculosis  may  often  be  followed  by 
a  positive  result  of  animal  inoculations.  The  centrifuged  sediment,  if 
injected  into  the  peritoneal  cavity  of  guinea-pigs,  is  almost  always  suc- 
ceeded b}'  the  development  of  general  miliary  tuberculosis,  which  is  found 
at  autopsy  after  the  lapse  of  from  three  to  five  weeks.  The  cytologic 
findings  are  not  without  some  diagnostic  significance,  although  a  study 
of  the  morphologic  character  of  the  cells  is  seldom  practised  by  the 
clinician.  The  presence  of  mononuclear  cells,  of  course,  suggests  the 
greater  possibility  of  finding  tubercle  bacilli.  Colombino  has  noted 
certain  important  changes  in  the  leukocytes,  occurring  exclusively  in 
tuberculous  infection  of  the  genito-urinary  passages.  The  outline  is 
described  as  angular  and  irregular,  and  the  cells  are  elongated  and 
grooved.     Sometimes  the  nuclei  are  entirely  detached. 

Cystoscopic  examination  of  the  bladder  is  of  considerable  importance 
on  account  of  the  opportunity  afforded  for  inspecting  the  ureteral  orifices, 
for  noting  the  presence  or  absence  of  ulceration,  for  comparing  the  size 
of  the  openings  upon  the  two  sides,  and  observing  the  flow  of  the 
urine  from  each  kidney.  Decided  hyperemia  in  the  immediate  vicinity 
of  one  orifice  is  strongly  suggestive  of  a  descending  tuberculosis  of  the 


TUBERCULOSIS    OF    THE    KIDNEY  495 

kidney  of  the  corresponding  side.  Ulcerative  changes  at  this  point, 
with  dilatation  of  the  mouth  of  the  ureter,  are  regarded  as  almost  pathog- 
nomonic of  the  conilition.  Kelly  has  referred,  however,  to  an  instance 
of  erroneous  selection  of  a  kidney  for  removal,  occasioned  by  the  presence 
of  ureteral  dilatation  upon  the  unaffected  side.  He  also  reports  a  rare 
case  of  primary  bladder  tuberculosis  in  which  one  orifice  was  much 
dilated  and  the  other  congested,  without  involvement  of  either  kidney, 
as  shown  when  first  one  and  then  the  other  was  opened  for  suspected 
renal  disease.  Cystoscopy  is  often  difficult  of  execution  because  of 
vesical  irritability  and  contraction,  but  may  sometimes  be  accomplished 
even  in  unfavorable  cases,  by  the  injection  of  :i  cuc'iiu  solution. 

The  use  of  the  x-ray  is  of  value  in  facilitat  Iul;  ■  lin  liin  isis  largely  through 
the  process  of  exclusion.  By  this  means  thr  imscnce  or  absence  of 
stone  may  be  determined  with  approximate  accuracy.  In  the  event 
of  enlargement,  detected  upon  palpation,  and  failure  to  demonstrate 
the  bacilli,  together  with  negative  a:-ray  examination,  Bevan  assumes  the 
probable  condition  to  be  simple  hypernephroma. 

The  segregation  of  urine  and  ureteral  catheterization  are  of  the  utmost 
importance  from  a  diagnostic  standpoint.  Their  value  consists  in  part 
of  the  means  presented  by  either  method  to  differentiate  in  many  cases 
the  healthy  from  the  affected  kidney.  The  urine  from  each  side  may  be 
examined  with  reference  to  its  quantity,  gross  appearance,  presence 
of  pus,  blood,  bacilli,  or  other  microorganisms.  The  unilateral  existence 
of  non-tuberculous  irritative  or  degenerative  change  may  also  be  detected 
in  this  manner.  By  the  use  of  the  Harris  segregator  or  by  catheteriza- 
tion there  is  permitted  a  determiiiMtinn  df  the  excretory  capacity  of 
each  organ.  Considerable  importance  h:is  been  attached  to  the  employ- 
ment of  elaborate  methods  of  urinary  cxaniiiuition  after  catheterization, 
in  order  to  ascertain  the  functional  power  of  each  kidney.  The  sup- 
posed need  of  such  investigation  is  the  necessity,  first,  of  unfailing 
accuracy  in  the  selection  of  the  diseased  kidney  for  operation,  and, 
secondly,  of  absolute  certainty  in  the  elimination  of  any  possible 
involvement  in  the  remaining  organ.  There  can  be  no  argument  as 
to  the  force  of  the  former,  but  the  recognition  of  the  diseased  kidney  is 
usually  clear  upon  the  <tfcnutli  of  the  symptoms,  and  special  aids  to 
diagnosis  previously  cnuniciaii'il.  It  is  believed  by  some  tliat  the  exist- 
ence of  a  slight  tubei'culdus  (•h.'inge  or  an  irritative  conditifin  in  one 
kidney  is  sufficient  to  contraindicate  the  jievfovmance  of  a  nephrectomy 
upon  the  other  side.  A  dissentmu  <ijiiHi(iii  i-^  ulTered  to  the  literal  inter- 
pretation of  such  general) zinji  si.atemenls.  although  due  cognizance  is 
taken  as  to  the  wisdom  of  non-intei'feicnie  w  it  h  a  badlx  diseased  kidney 
in  the  face  of  decided  ini])airnient  of  funct  ion  oi  it-  fellow  ,  The  rerog- 
nition  of  but  a  slight  invohcinent.  wlielhei  t  iilieniilons  or  oi  lieiwise, 
does  not  invariably  jiredicate  the  .assuniption  as  to  tlie  futility  of  sur- 
gical operation  upon  the  kidiie\'  of  the  oppo-iie  side.  The  removal  in 
toto  of  a  considerable  focus  of  tulierrulous  and  sometimes  of  mixed  infec- 
tion is  likely  to  be  followed  by  marked  improvement  in  the  other  kidney. 
A  similar  result  is  sometimes  observed  in  the  tuberculous  process 
involving  the  bladder  and  prostate  after  nephrectomy,  in  cases  of 
descending  infection,  or  after  castration,  in  cases  of  the  ascending  type. 
Freeman  has  referred  to  a  case  reported  by  Kiimmel  in  which  a  badly 
diseased  left  kidney  was  removed  in  spite  of  coe.xisting  tuberculosis  of 
the  organ  upon  the  opposite  side,  of  the  bladder,  of  both  testicles  and 


496  COMPLICATIONS 

both  seminal  vesicles,  together  with  a  tuberculous  peri-urethral  abscess. 
An  immediate  and  pronounced  improvement  ensued,  and  the  patient 
was  enabled  to  return  to  his  work. 

There  are  three  distinct  metliods  more  or  less  in  vogue  for  the  deter- 
mination of  the  relative  crcrdorn  capacity  of  each  kidney,  all  involving 
the  separate  e.xamination  of  the  urine  after  catheterization  or  segregation. 
The  most  simple  and  perhaps  the  most  accurate  method  is  the  compari- 
son of  the  amount  of  urea  excreted  by  the  two  kidneys,  a  diminution 
in  the  elimination  of  the  normal  amount  of  urea  from  either  kidney 
indicating,  of  course,  a  corresponding  impairment  of  its  excretory  func- 
tion. 

Another  method  is  known  as  the  phlorizin  test.  The  injection  of 
Jjy  grain  of  phlorizin  produces  almost  immediately  an  active  tendency 
on  the  part  of  the  kidney  to  withdraw  sugar  from  the  blood,  resulting 
in  the  presence  of  glucose  in  the  urine.  A  comparison  of  the  amount 
of  sugar  in  the  urine  from  the  respective  kidneys  after  the  administration 
of  phlorizin,  affords  an  appro.ximate  estimate  of  their  relative  excreting 
power.  A  normal  kidney  should  excrete  in  the  neighborhood  of  1  per 
cent.  A  marked  reduction  from  this  amount  upon  the  other  side  would 
indicate  a  considerable  impairment  of  function. 

Cryoscopn  consists  of  a  comparison  of  the  freezing-points  of  the 
urine  from  the  two  kidneys.  The  test  as  sometimes  employed  includes 
a  determination  of  the  freezing-point  of  the  blood,  which  should  nor- 
mally be  from  —0.56°  C.  to  —0.58°  C.  The  freezing-point  of  any  fluid  is 
known  to  vary  according  to  differences  in  its  specific  gravity.  Thus, 
the  freezing-point  is  lower  directly  in  proportion  to  the  reduction  of  the 
specific  gravity.  The  specific  gravity  of  the  urine,  though  subject  to 
continual  variation,  nevertheless  affords  a  fair  estimate  as  to  the  reten- 
tion of  salts  in  the  circulation.  According  to  Morton,  the  practice 
most  frequently  employed  in  making  the  cryoscopic  test  relates  to  the 
comparison  of  the  freezing-points  of  the  urine  taken  from  the  right  and 
left  kidneys  at  the  same  time.  He  believes,  first,  a  low  freezing-point 
of  each  urine  to  indicate  a  normal  excretion;  secondly,  a  high  freezing- 
point  to  suggest  a  diminished  excretion  upon  each  side;  third,  a  high 
freezing-point  upon  one  side  and  a  low  upon  the  other  to  demonstrate 
an  impaired  and  a  normal  function  respectively.  The  limitations  and 
deficiencies  of  this  method  for  general  application  are  at  once  apparent. 

The  prognosis  in  renal  tuberculosis  is,  of  course,  dependent  upon 
the  general  condition,  the  existence  of  tuberculous  lesions  in  other  parts 
of  the  body,  the  involvement  of  but  one  or  of  both  kidneys,  and  their 
degree  of  functional  capacity.  The  course  is  usually  slow  and  pro- 
tracted. 

The  treatment  varies  according  to  the  stage  of  the  disease,  the 
general  health,  the  existence  of  tuberculous  processes  in  other  parts 
of  the  genito-urinary  tract  or  in  remote  portions  of  the  body,  and  the 
development  of  complications,  as  amyloid  disease,  nephritis,  or  perineph- 
ritic. abscess.  The  latter,  in  all  cases,  calls  for  immediate  surgical  inter- 
ference. Free  incision  is  indicated  in  order  to  promote  evacuation  of 
the  pus. 

The  rational  management  of  renal  tuberculosis  may  be  regarded  as 
climatic  and  hygienic,  surgical  and  palliative.  Sole  recourse  to  general 
measures  of  treatment,  including  change  of  climate  and  judicious  exer- 
cise in  the  open  air,  is  obviously  appropriate  but  to  very  early  cases. 


TUBERCULOSIS    OF    THE    KIDNEY 


497 


As  a  matter  of  fact,  tuberculosis  of  the  kidney  is  rarely  recognized  in 
its  incipiency,  and  after  the  disease  has  passed  this  period,  there 
exists  but  slight  justification  for  delay  in  resorting  to  radical  surgical 
operation.  Procrastination  at  this  time  is  met  with  the  unanswerable 
argument  that  there  is  practically  nothing  to  gain  by  delay,  and  immi- 
nent danger  of  descending  infection  to  the  bladder,  as  well  as  extension 
to  the  kidney  of  the  opposite  side,  as  shown  by  the  comparative  autopsy 
statistics  of  bilateral  affection.  It  is  true,  however,  that  in  exceptional 
instances  satisfactory  results  are  secured  by  climatic  and  hygienic 
management,  suggesting  the  propriety  of  utilizing  these  measures  for  a 
time  in  cases  exhibiting  the  earliest  stage  of  infection.  It  is  recognized 
that  it  may  be  extremely  difficult  to  differentiate  between  the  early  cases 


Skiagraph  showing  large  oval  tumor  of  le 
gin.     (For  description  of  case  see  p.  748. J 


of  left  kidney  of  tuberculous 


appropriate  for  climatic  and  hygienic  management,  and  those  suited  for 
immediate  operation.  It  must  be  admitted,  also,  that  it  is  in  precisely 
this  class  of  cases  that  the  most  satisfactory  results  of  operative  sur- 
gery upon  the  kidney  are  attained.  The  following  considerations,  how- 
ever, afford  a  justification  of  occasional  recourse  to  general  measures 
before  resorting  to  radical  operation:  the  earlier  recognition  of  the  dis- 
ease than  formerly;  the  means  afforded  for  securing  a  fairly  accurate 
determination  of  the  progress  through  frequent  urinary  examinations; 
the  excellent  results  not  infrequently  attained  by  hygienic  management 
in  incipient  cases;  the  great  importance  of  the  kidney  to  the  vital 
economy,  and,  finally,  the  knowledge  that  even  with  the  removal  of 
the  diseased  kidney  the  primary  focus  still  remains  in  the  body  and 
may  constitute  the  source  of  future  infection. 


498  COMPLICATIOXS 

It  is  probable  that  the  tubercle  bacilli  emulsion  of  Koch  in  properly 
adjusted  and  interspaced  doses  is  capable  of  a  favorable  influence  upon 
the  course  of  the  disease  in  some  instances,  and  often  to  a  remarkable 
degree.  In  the  event  of  secondary  infection  a  culture  should  be  taken 
of  the  microorganisms  present,  and  a  vaccine  made  for  inoculation  pur- 
poses. The  bacterial  vacciiie  may  be  prepared  either  from  the  urine  or 
from  the  discharge  of  a  periii<'|iliiitii-  aliscess  or  both.  In  two  cases  of 
kidney  disease  recently  under  dl.^ci  vation.  infection  with  the  colon 
bacillus  was  pronounced,  in  one  iu-stanee  accompanying  a  well-defined 
tuberculous  involvement  of  the  kidney,  and  in  the  other,  closely  simu- 
lating the  latter  condition.  The  degree  of  gross  pathologic  change 
incident  to  the  tuberculous  kidney  is  suggested  in  the  radiograph 
(Fig.  126). 

The  operative  measures  relate  to  the  performance  of  nephrotomy 
or  nephrectomy. 

Nephrotomy  is  indicated  only  when  the  concUtions  present  are  of 
such  a  nature  as  to  contraindicate  an  immediate  nephrectomy.  In  cases 
of  mixed  infection  the  best  results  are  obtained  by  an  initial  nephrotomy, 
the  more  radical  operation  being  delayed  until  the  subsidence  of  the 
fever,  and  improvement  in  the  general  health.  The  same  rule  of  pro- 
cedure obtains  in  cases  of  great  debility  from  any  cause.  Nephrotomy 
is  also  the  more  advisable  operation,  as  a  general  rule,  in  the  event  of 
considerable  involvement  of  both  kidneys.  The  operation  consists  of 
simple  incision  to  promote  the  immecUate  evacuation  of  pus  and  to 
afford  subsequent  drainage.  The  wound  is  left  to  heal  by  granulation, 
but  a  permanent  tuberculous  sinus  often  results. 

Nephrectomy  or  total  extirpation  of  the  diseased  kidney  is  the  oper- 
ation of  choice.  The  best  results  are  to  be  expected  in  the  absence  of 
other  tuberculous  lesions  either  in  the  genito-urinary  tract  or  elsewhere. 
The  presence  of  tuberculous  deposit  in  the  bladder,  lungs,  bones,  and  joints 
should  not  effectually  prechule  the  operation,  provided  the  incUcations 
for  its  performance  are  sufficiently  clear  upon  the  score  of  the  kidneys 
themselves.  Tuberculosis  of  tlie  bladder  often  undergoes  a  remarkable 
improvement  after  nephrectomy.  This  may  be  accounted  for  in  part 
by  the  fact  that  the  irritability  of  the  bladder  is  aggravated  Ijy  a  descend- 
ing cUscharge  from  the  diseased  kidney.  The  expediency  of  nephrec- 
tomj^  among  phthisical  iiaticnts  must  be  determined  to  some  extent 
upon  the  basis  of  the  ]iuhnciii:iry  condition.  If  the  tuberculous  process 
in  the  lungs  is  comparati\  cly  inactive  and  not  accompanied  by  extensive 
destructive  change,  the  possibility  of  securing  an  eventual  arrest  must  be 
admitted.  In  this  event  there  should  be  no  hesitation  in  according 
to  the  consumptive  the  benefit  of  nephrectomy,  if  indicated  upon  the 
merits  of  the  kidney  involvement.  While  it  is  true  that  the  immediate 
outlook  is  considerably  less  favorable  by  virtue  of  the  pulmonary  com- 
plication, the  fact  remains  that  the  ultimate  prognosis  as  regards  the 
tuberculous  process  in  the  lung  is  rendered  much  more  favorable  by  the 
elimination  of  a  large  focus  of  infection  in  the  kidney.  The  results  of 
operation  at  the  present  time  exhibit  a  decidedlj'  lower  mortality  than 
in  earlier  years.  In  1885  Gross,  as  quoted  by  Bevan,  reported  upon 
the  results  of  20  cases  obtained  from  the  literature,  with  12  recoveries 
and  8  deaths.  Since  this  time  the  statistics  as  reported  by  various 
observers  show  a  diminishing  mortality  attending  the  operation.  In 
1892  the  death-rate  was  reported  to  vary  from  28  per  cent,  to  50  per 


TUBERCULOSIS    OF    THE    BLADDER  499 

cent.  The  reports  of  Ramsay,  Israel,  Kronlein,  Kiimmel.  Rumbel, 
Bangs,  Facklan,  and  Garceau  demonstrate  more  successful  results, 
presumably  from  a  better  selection  of  cases  and  an  improved  technic. 
Garceau,  in  a  series  of  101  cases  quoted  from  various  sources,  finds 
the  mortality  to  be  17  per  cent.  Kelly  reports  57  cases  with  4  deaths, 
establishing  a  primary  mortality  of  7  per  cent. 

The  kidney  is  exposed  by  an  olilii|iic  iiirision  extending  approxi- 
mately from  the  last  rib  to  the  cro.'^t  ^>i  the  ilium.  Upon  bringing  the 
kidney  outside  of  the  wound  the  vessels  uro  ligated  with  strong  catgut. 
Considerable  difference  of  opinion  is  entertained  ic^ardiim  tlie  advis- 
ability of  removal  of  the  ureter  if  diseasetl.  This  |ir(i(ciliirc  is  recom- 
mended by  some  on  account  of  the  frequent  developnieul  of  fistula 
and  lumbar  abscess,  with  possible  danger  of  further  dissemination 
of  the  disease.  It  is  Relieved  by  many  that  the  ureter,  even  though 
partially  diseased,  should  be  retained  because  of  the  increased  danger 
and  extent  of  the  operation.  Tuberculous  sinuses  arising  from  this 
source  sometimes  cUsappear  after  a  few  months.  No  objection  is  made 
to  the  removal  of  a  portion  of  a  diseased  ureter,  and  cauterization  of  the 
distal  end  with  pure  phenol  when  unattended  by  special  difficulty  or  too 
great  prolongation  of  the  operation. 


CHAPTER   LXXII 
TUBERCULOSIS  OF  THE  BLADDER 

This  condition,  in  the  great  majority  of  in.stances,  is  secondary  to 
tuberculous  change  in  other  parts  of  the  genito-urinary  system.  It 
may  occur  as  a  result  of  either  ascending  or  descending  infection.  It 
is  probable  that  the  larger  proportion  of  cases  of  bladder  tuberculosis 
take  place  as  an  extension  from  a  primary  lesion  in  one  kidney.  Involve- 
ment of  the  bladder  may  occur  as  a  result  of  ascending  infection  from 
portions  of  the  genital  system,  in  accordance  with  Baumgarten's  law 
regarding  the  flow  of  the  secretions.  It  is  extremely  doubtful,  how- 
ever, if  the  original  source  of  infection  in  any  considerable  numlier  of 
cases  is  traceable  to  the  external  genitals.  In  other  words,  the  primary 
infection  in  all  portions  of  the  genito-urinary  tract  is  usually  hemato- 
genous rather  than  exogenous  in  origin. 

Though  of  rare  occurrence,  primary  tuberculosis  of  the  bladder  is 
sometimes  observed.  It  must  be  remembered,  as  previously  stated, 
that  the  term  primary,  as  applied  in  this  connection,  refers  simply  to 
the  genito-urinary  tract,  exclusive  of  infoc'tion  in  other  parts  of  the 
body.  Primary  vesical  tuberculosis  is  i-ather  more  common  among 
females  than  in  the  opposite  sex,  and,  according  to  Fournier,  is  occa- 
sionally due  to  infection  from  the  female  genitals.  The  pathologic 
changes  relate  essentially  to  the  formation  of  small  grayish  nodules, 
which  enlarge,  caseate,  assume  a  yellowish  appearance,  and  eventually 
ulcerate.  The  ulcerations  often  exhibit  an  irregular  contour  on  account 
of  the  coalescence  of  multiple  tubercle  deposits.  They  vary  not  only 
in  their  lateral  distribution,  but  to  some  extent  as  well  in  depth. 
Though  superficial,  in  many  instances  involving  merely  the  mucosa  or 


500  COMPLICATIONS 

submucosa,  in  exceptional  cases  they  penetrate  the  vesical  wall,  and 
produce  perforations  into  the  rectum  or  vagina.  The  ulcers  are  usually 
sui-founded  by  a  zone  of  more  or  less  intense  hyperemia.  In  fact,  before 
ulceration  has  taken  place  the  only  deviation  from  the  normal  macro- 
scopic appearance  may  consist  of  reddened,  irregular  patches  of  mucous 
meml)rane. 

Symptoms  and  Diagnosis. — The  s3'mptoms  are  often  of  slow  develop- 
ment. They  may  remain  unrecognized  for  a  considerable  period  or  they 
may  suggest  merely  a  varying  degree  of  vesical  irritability.  Complaint 
is  rarely  made  of  pain  in  the  beginning  of  the  affection,  but  later  this 
becomes  a  prominent  symptom.  Early  attention  is  usually  called  to 
the  contlition  by  the  frequency  of  urination.  Examination  of  the  urine 
at  this  time  discloses  the  presence  of  a  variable  amount  of  pus,  and  some- 
times of  blood.  The  latter  may  be  recognized  as  an  occasional  red  blood- 
cell,  or  in  some  cases  as  a  distinct  hematuria.  A  few  drops  of  clear 
blood  may  make  their  appearance  at  the  end  of  urination.  Failure  to 
explain  the  bladder  irritation,  and  the  presence  of  Ijlood  and  pus  by 
the  demonstration  of  stone  in  the  bladder  or  of  other  recognized  patho- 
logic condition,  suggests  immediately  the  probability  of  tuberculous 
infection.  This  hypothesis  is  substantiated  by  the  discovery  of  bacilli 
in  the  urine,  although  their  non-recognition  upon  microscopic  search 
of  the  sediment  constitutes  no  negative  evidence  as  to  their  presence. 
The  tliagnosis  may  be  definitely  estalilished  by  a  positive  result  of  animal 
inoculation. 

Cystoscopy,  even  at  an  early  period,  may  )'^ield  information  of  almost 
pathognomonic  character.  Irregular  reddened  patches  of  mucous 
membrane  may  be  recognized,  which  are  frequently  situated  in  the 
trigonum.  In  case  of  descending  infection  from  one  kidney  there 
is  usually  observed,  as  already  described,  a  distinct  reddening  and 
dilatation,  with  or  without  ulceration  of  the  ureteral  orifice.  It  maj' 
be  assumed  that  the  absence  of  dilatation  and  ulceration  at  the  mouth 
of  both  ureters,  with  tuberculous  nodules  and  ulcerations  in  other  portions 
of  the  bladder  is  prima  facie  evidence  that  the  infection  is  either  ascend- 
ing in  character  or  primary  in  the  bladder,  ilej'er  reports  a  single 
instance  of  contraction  of  the  ureteral  orifice  in  tuberculosis  of  the  corre- 
sponding kidney. 

After  the  tuberculous  lesions  in  the  bladder  undergo  the  process  of 
ulceration,  the  general  type  of  the  symptoms  assumes  a  greater 
degree  of  severity.  The  desire  to  urinate  is  more  frequent  and  impera- 
tive. Sleep  is  sometimes  well-nigh  impossible,  as  the  patient  is 
awakened  at  brief  intervals  by  urgent  vesical  discomfort.  Pain  is  often 
very  intense,  and  may  be  accompanied  by  considerable  tenesmus. 
Though  the  bladder  capacity  often  becomes  much  diminished,  the  reten- 
tion of  a  variable  amount  of  residual  urine  may  take  place.  Incon- 
tinence sometimes  occurs  if  the  ulcerative  process  involves  the  neck  of 
the  bladder.  The  rapidity  of  the  development  of  symptoms  varies 
somewhat  with  the  location  of  the  ulcerative  changes.  If  the  trigonum 
is  involved,  the  evolution  of  clinical  manifestations  is  considerably 
more  rapid  than  when  the  process  does  not  invade  this  region.  After 
ulceration  has  become  established,  a  secondary  infection  almost  inevit- 
ably supervenes,  and  adds  to  the  sufferings  of  the  patient,  already 
sorely  afflicted,  .\ppetite  and  nutrition  l)ecome  impaired,  and  nervous 
disturbances  pronounced. 


TUBERCULOSIS  OF  THE  BLADDER  501 

Treatment. — The  treatment  of  bladder  tuberculosis  is  attended 
by  much  more  gratifying  results  than  in  former  years.  In  early  states 
the  management  of  the  vesical  affection  itself,  exclusive  of  the  surgical 
indications  relating  to  operation  upon  other  portions  of  the  genito- 
urinary tract,  should  be  based  upon  the  principles  of  nutrition  and  rest. 
As  in  other  tuberculous  conditions,  the  utmost  importance  attaches  to 
the  establishment  of  the  best  possible  hygienic  environment.  Rest,  as 
a  rule,  is  more  imperative  than  in  any  other  tuberculous  infection, 
although  moderate  exercise  may  sometimes  be  permitted  if  carefully 
supervised.  The  patient,  in  the  event  of  suitable  weather  conditions, 
should  be  exposed  to  the  open  air  for  prolonged  periods,  but  the  fullest 
conception  of  the  principles  of  outdoor  living  is  capable  of  fulfilment 
only  in  regions  where  sunshine,  blue  skies,  and  an  invigorating  atmos- 
phere predominate. 

The  climatic  conditions  appropriate  to  the  successful  management 
of  pulmonary  tuberculosis  are  those  most  likely  to  influence  favorably 
the  course  of  tuberculous  processes  in  other  parts  of  the  body. 

Treatment  with  the  bacilli  emulsion,  or,  in  case  of  mixed  infection, 
with  other  bacterial  vaccines,  may  occasionally  be  attended  by  favor- 
able results. 

The  local  treatment  of  vesical  tuberculosis  as  generally  employed  is 
most  unsatisfactory.  The  injection  of  various  solutions  into  the  bladder 
is  likely  to  be  productive  of  considerable  pain  and  discomfort.  In  the 
presence  of  a  very  acid  urine,  the  injection  of  mild  cleansing  solutions, 
as  boric  acid,  sometimes  exerts  temporarily  a  soothing  effect  upon  the 
inflamed  mucous  membrane.  The  injection  of  iodoform  suspended  in 
olive  oil  has  been  more  or  less  employed,  with  varjdng  reports.  Agents 
directed  to  the  relief  of  the  bladder  symptoms  should  be  selected  not 
only  with  reference  to  the  acuteness  of  the  clinical  manifestations,  the 
condition  of  the  urine,  the  presence  or  absence  of  mixed  infection,  but 
primarily  to  the  stage  of  the  tuberculous  process.  Nodular  tuberculosis 
is  not  attended  by  secondary  infection,  and  scarcely  calls  for  local 
applications  of  any  kind.  Instrumentation  of  the  bladder  at  this  period 
should  be  absolutely  avoided,  as  the  topical  solutions  do  not  come  in 
actual  contact  with  the  local  tuberculous  process,  while  added  oppor- 
tunity is  afforded  for  the  introduction  of  secondary  microorganisms  into 
the  bladder.  Unnecessary  irritation  is  often  induced,  and  the  course  of 
the  tuberculous  disease  thereby  hastened. 

Rest  and  attention  to  the  general  health  are  of  especial  importance 
at  this  time.  Diluents  should  be  administered,  and  excesses  of  all 
kinds  enjoined,  especially  indulgence  in  alcohol,  coffee,  or  highly  spiced 
food.  Urotropin  is  of  some  utility  in  case  of  an  alkaline  urine,  especially 
if  bacilluria  is  present,  although  this  rarely  precedes  ulceration  unless 
as  a  result  of  careless  catheterization.  If  ilic  mine  is  highly  acid,  alka- 
line diuretics  are  indicated,  to  which  tiiirluir  <<(  liyoseyamus  may  be 
added  in  the  event  of  extreme  vesical  irrit:il)ility.  Mter  the  ulcerative 
process  has  become  established  and  secondary  infection  has  supervened, 
considerable  benefit  may  be  obtained  from  the  intelligent  use  of  various 
strong  antiseptics.  Solutions  of  corrosive  sublimate,  as  originally 
advocated  by  Guyon,  have  been  quite  extensively  employed.  Garceau 
recommends  the  early  instillation  of  a  solution  of  1  :  5000  into  the  blad- 
der in  case  of  vesical  tuberculosis  in  the  female.  With  increasing  tolera- 
tion for  the  drug  the  strength  is  increased  up  to  1  :  500.     If  the  pain 


502  COMPLICATIONS 

is  severe  an  injection  of  cocain  or  eucain  is  advised  as  a  preliminary 
procedure.  He  also  practises  the  application  of  solid  silver  nitrate  to 
the  diseased  surface  by  means  of  the  cystoscope,  with  the  patient  in  the 
knee-chest  position.  "Etherization  is  sometimes  necessary  for  the 
initial  exploration  and  application.  Tuberculous  granulations  are 
reported  to  have  been  destroyed  by  this  method,  and  the  process  of 
healing  decidedly  stimidated.  The  application  of  silver  nitrate  in  solu- 
tion to  the  tuberculous  bladder  of  males  has  been  attended  by  much 
less  favorable  results.  Rovsing,  of  Copenhagen,  has  obtained  remark- 
able results  by  the  injection  of  5  per  cent,  solution  of  phenol  into  the 
bladder  subsequent  to  cocainization. 

The  surgical  treatment  of  vesical  tuberculosis  relates  to  the  curet- 
ment  of  tuberculous  ulcers,  excision  of  portions  of  the  bladder,  and 
cystotomy. 

Curetment  is  practised  through  a  large  cystoscope,  and  is  applicable 
only  to  large  active  granulations  covering  a  localized  area  of  ulceration. 
If  curetment  is  performed,  it  is  usually  necessary  to  cauterize  the  base 
of  the  ulcer  with  the  silver  nitrate.  The  operation  is  impracticable  in 
most  cases,  and  is  attended  by  the  disadvantage  of  possible  further 
dissemination  of  the  infection. 

Excision  of  tuberculous  ulcers,  or  even  of  a  considerable  portion 
of  the  wall  of  the  bladder,  has  been  practised  in  occasional  instances, 
but  the  proper  scope  of  its  application  is  very  limited.  An  important 
objection  to  its  more  general  use  is  the  fact  that  the  ulcerative  process 
involves  with  great  frequency  the  vicinit}'  of  the  ureters,  in  which  locality 
excision  is  rarely  permissible. 

Cystotomy  is  the  operation  of  choice  on  account  of  its  comparative 
safety,  and  the  immediate  relief  afforded  to  the  patient,  whose  sufferings 
have  been  well-nigh '  intolerable.  It  is  especially  indicated  in  severe 
continuous  bladder  discomfort,  with  almost  incessant  efforts  toward 
urination.  The  torture  resulting  from  advanced  tuberculosis  of  the 
bladder  is  almost  instantly  relieved  by  the  opportunity  provided  for 
immediate  evacuation  of  the  urine. 

For  women  the  infrapubic  operation  is  recommended  by  some  sur- 
geons, the  vagina  being  regarded  the  natural  route  for  drainage.  It 
would  appear,  however,  that  while  vaginal  cystotomy  has  obvious 
advantages,  a  decided  objection  to  its  employment  relates  to  the  fact 
that  operation  through  this  channel  is  especially  likely  to  invade  the 
area  of  active  tuberculous  ulceration,  and  open  up  fresh  avenues  of 
infection.  This  objection  does  not  obtain  to  the  same  extent  in  the 
suprapubic  operation.  In  1902  Dr.  C.  A.  Powers  reported  a  case  of 
suprapubic  drainage  for  advanced  tuberculo.sis  of  the  bladder  upon  a 
patient  of  Dr.  S.  A.  Fisk,  who  subsequently  came  under  my  observation. 
As  the  case  is  somewhat  unique  in  view  of  the  excellent  resvdt  attending 
the  operation,  extracts  of  Dr.  Powers'  report  are  appended.  The 
patient  was  a  man,  fifty  years  of  age;  his  wife  and  two  daughters  had 
died  of  pulmonarv  phthi.sis,  and  one  son  was  the  subject  of  existing 
tuberculous  infection. 

"The  patient  is  of  rather  spare  physique,  who  appears  to  be  between 
sixty  and  sixty-five  years  of  age.  Examination  of  the  chest  negative. 
Vesical  discomfort  and  tenesmus  are  urgent.  He  urinates  every  half- 
hour,  both  day  and  night.  He  takes  three-quarters  of  a  grain  of  mor- 
phin  daily.     His  bladder  capacity  at  this  time  is  about  one  ounce;  there 


TUBERCULOSIS    OFTHE    BLADDER  503 

is  about  one-half  ounce  of  residual  urine.  The  urine  is  pale,  neutral,  its 
specific  gravity  1014.  It  contains  bacteria,  bladder  epithelium,  mucus, 
and  a  little  pus.  Tubercle  bacilli  are  sought,  but  not  found.  Cocain 
examination  for  stone  is  negative;  the  introduction  of  the  searcher 
causes  slight  bleeding.  So  far  as  one  can  judge,  there  is  no  other  tuber- 
culous lesion  in  the  genito-urinary  tract." 

After  the  lapse  of  two  years  the  patient  again  came  under  obser- 
vation. His  condition  had  grown  progressively  worse.  There  was 
marked  spasm  at  the  neck  of  the  bladder;  urination  was  performed 
every  ten  minutes,  day  and  night;  hematuria  was  constant.  Four 
grains  of  morphin  were  taken  daily. 

"  He  was  examined  under  chloroform  December  26,  1896.  Bladder 
capacity,  about  six  drams.  Cystoscopic  examination  revealed  an  irregu- 
lar ulcer,  three-quarters  of  an  inch  in  diameter,  at  the  neck  of  the  bladder 
posteriorly.  This  ulcer  bled  very  easily.  No  stone  was  found.  After 
prolonged  search  tubercle  bacilli  were  found  in  the  urine." 

Permanent  suprapubic  drainage  was  performed.  The  bladder  was 
found  not  larger  than  an  English  walnut.  The  wall  was  greatly  thick- 
ened, intensely  congested,  and  studded  here  and  there  with  miliary 
tubercles. 

"There  was  an  irregular  ulcer  the  size  of  a  penny  at  the  neck  poste- 
riorly, rather  more  on  the  left  side.  The  ulcer  was  gently  curetted,  and 
its  base  cauterized  with  pure  phenol.  It  bled  pretty  freely.  The 
bladder  was  drawn  up  and  its  edges  stitched  to  the  skin.  It  seemed  to 
resemble  in  size  and  shape  the  finger  of  a  glove.  The  orifices  of  the 
ureters  were  not  seen.  A  large  drainage-tube  was  placed  in  the  bladder, 
care  being  taken  that  its  end  should  not  touch  the  posterior  wall,  and 
the  bladder  was  tightly  sewn  about  it.  The  outer  wound  was  partially 
closed. 

"The  patient  was  out  of  bed  on  the  tenth  day,  and  at  the  end  of 
three  weeks  was  wearing  a  permanent  tube  and  urinary  receptacle.  At 
that  time  his  morphin  had  been  decreased  to  two  grains  daily.  A 
month  later  he  resumed  his  occupation,  that  of  traveling  aucUtor  for 
a  large  national  corporation.  During  the  two  or  three  months  imme- 
diately following  the  operation  there  was  occasionallj'  moderate  leak- 
age about  the  tube.  The  tube  itself  was  a  soft-rubber  catheter,  No.  30 
of  the  French  scale,  having  a  velvet  eye  at  the  end.  as  well  as  at  the  side. 
It  was  carefully  adjusted  mu\  held  well  in  place.  Twice  daily  the  ]iaticnt 
removed  and  "boiled  the  eii(ii-e  apparatus  and  washed  <iut  iiis  Idadilev. 
His  relief  from  suft'erin;.^  was  marked,  and  he  \\as  quite  comfortable. 
His  spirits  returned,  he  gained  in  fiesh  and  stren,t!;th,  and  was  able  to 
decrease  his  morphin  to  sonietiiing  less  than  a  grain  daily. 

"The  patient  continued  from  year  tn  ye.ii'  in  a  comfortable  and  gen- 
erally satisfactory  condition.  A(  ikj  time  did  I  think  it  wise  to  rec- 
ommend removal  of  the  tul.e  and  chisiiri'  of  the  fistula.  I  saw  and 
examined  him  yearh',  as  once  a  3ear  his  business  brought  him  to  Denver 
for  two  or  three  weeks.  I  last  saw  him  in  i  he  summer  of  1901.  four  and 
one-half  years  after  operation.  At  that  time  he  was  in  better  weight 
and  general  health  than  in  many  years.  He  was  comfortable,  except 
for  the  nuisance  of  the  urinary  fistula." 


COMPLICATIONS 


CHAPTER   LXXIII 


TUBEROn^OSIS  OF  THE  PROSTATE  AND  SEMINAL 
VESICLES 

TUBERCULOSIS  OF  THE  PROSTATE 

Involvement  of  the  prostate  is  exceedingly  frequent  in  genito-urin- 
ary  tuberculosis,  and  is  undoubtedly  more  common  as  a  primary  infection 
than  was  formerly  thought  to  be  the  case.  It  is  difficult,  however, 
to  conceive  of  its  primary  involvement  save  upon  an  assumption  of 
infection  by  way  of  the  blood-channels.  The  mere  fact  of  primary 
tuberculous  disease  in  the  prostate  constitutes  in  itself  no  evidence  upon 
which  to  construct  a  theory  of  exogenous  infection.  Some  observers 
have  been  prone  to  regard  the  primary  origin  of  the  disease  in  this 
organ  to  result  essentially  from  careless,  unclean  instrumentation  and 
eroded  mucous  svu-faces.'  This  appears  hardly  tenable,  first,  because 
of  the  comparative  infrecpiency  of  such  a  history  in  cases  of  primary 
prostatic  tuberculosis,  and,  serondly,  because  of  the  mechanic  obstacles 
offered  to  the  retention  and  colonization  of  bacilli  in  the  urethral  canal, 
by  the  forceful  washing  of  the  urinary  stream.  After,  however,  an  initial 
tuberculous  infection  of  other  portions  of  the  genito-urinary  system,  the 
anatomic  conditions  are  such  as  peculiarly  to  favor  a  secondary  involve- 
ment of  the  prostate.  Its  situation  at  the  intersection  of  the  genital 
and  urinary  systems  produces  an  increased  exposure  to  secondary  infec- 
tion. In  addition  a  tuberculous  prostatic  change  having  taken  place, 
its  location  renders  it  a  favorable  point  of  ileparture  of  further  tuber- 
culous dissemination.  It  thus  happens,  irrespective  of  the  primary 
focus,  that  this  gland  rarely  escapes  infection  in  case  of  urogenital 
tuberculosis.  It  is  more  or  less  immaterial,  therefore,  whether  the  dis- 
ease is  the  result  of  an  ascending  infection  from  the  epididymis,  or  of  a 
descending  involvement  from  the  kidney  or  bladder,  as  it  is  well  known 
that  the  prostate  may  be  the  receptacle  of  bacilli  from  either  source. 
It  is  doubtful,  however,  if  its  secondary  involvement  occurs  with  fre- 
quency as  a  direct  result  of  bladder  tuberculosis.  As  between  these  two 
organs,  it  is  probable  that  the  disease  extends  from  prostate  to  bladder 
much  oftener  than  from  blatider  to  prostate. 

The  symptoms  of  prostatic  tuberculosis  may  be  completely  over- 
shadowed by  the  manifestations  of  vesical  disea.se.  In  such  an  event  the 
diagnosis  is  establishc(  1  cm  ii el  \  ui)on  the  results  of  physical  examination. 
In  other  cases,  in  addition  to  the  evidences  of  bladder  irritability  pre- 
viously described,  there  may  take  place  from  the  urethra  a  discharge 
of  mucus  or  pus,  in  which  tubercle  bacilli  are  found.  There  is  some- 
times present  an  appreciable  tenderness  in  the  perineal  region,  with  a 
sense  of  dragging  weight.  Physical  examination  through  the  rectum 
discloses  the  existence  of  prostatic  enlargement  and  sometimes  of  hard, 
nodular  masses  of  varying  size,  which  often  break  down  and  form 
abscesses.  The  size  of  the  prostate  ia  largely  a  relative  matter  in  differ- 
ent individuals,  and  the  diagnosis  upon  examination  rests  iliiefly  upon 
the  prseence  of  the  small  nodular  lumps  which  are  sometimes  entirely 
unproductive  of  subjective  symptoms.  Catheterization,  however,  is 
usually  attended  by  considerable  pain. 


TUBERCULOSIS    OF    THE    PROSTATE    AND    SEMINAL    VESICLES        505 

The  treatment  of  this  condition  per  se  is  largely  climatic,  hygienic, 
and  symptomatic.  If  tuberculous  disease  exists  in  other  parts  of  the 
genito-urinary  system,  the  general  principles  of  management  are 
based  essentially  upon  the  indications  presented  by  the  other  tubercu- 
lous processes.  In  other  words,  the  treatment  of  the  prostatic  affection 
is  often  quite  subordinate  to  that  of  infection  in  other  regions.  In  case 
of  primary  involvement  limited  to  the  prostate  tlie  jieneral  management 
should  conform  to  the  hygienic  and  climatic  considerations  recom- 
mended for  tuberculosis  of  the  kidney  anil  bladder.  It  has  been  demon- 
strated that  change  of  surroundings  and  immediate  environment  may 
be  attended  with  beneficial  results.  A  prolonged  sea  voyage  is  often 
advocated  for  such  invalids,  provided  other  complications  do  not  exist. 
It  is  doubtful  if  injections  of  iodoform  in  olive  oil  possess  any  decided 
advantage,  though  sometimes  employed. 

In  view  of  the  peculiar  position  of  the  prostate  and  the  opportunities 
afforded  for  tubercidous  infection  in  other  portions  of  both  the  genital 
and  urinary  systems,  the  limitations  and  deficiencies  of  surgical  inter- 
ference are  particularly  unfortunate.  It  has  been  urged  that  the  sur- 
gery of  the  prostate  should  be  delayed  until  the  indications  for  active 
interference  are  urgent  in  character.  This  presupposes  not  only  that 
other  measures  have  failed  to  produce  satisfactory  results,  but  also  that 
sufficient  time  has  elapsed  for  the  extension  of  the  disease  to  other  portions 
of  the  genito-urinary  tract.  The  propriety  of  excision  of  the  prostate 
in  case  of  primary  tuberculous  involvement  prior  to  further  bacillary 
dissemination  is  a  matter  for  judicial  surgical  consideration.  As  there 
is  but  little  technical  difficulty,  either  to  suprapubic  or  perineal  prostat- 
ectomy, it  is  difficult  to  understand  why  the  same  rule  of  procedure 
as  regards  removal  is  not  applicable  to  the  prostate  as  to  the  kidney. 
It  would  even  appear  that  if  it  is  desirable  to  perform  nephrectomy 
upon  early  cases  of  primary  kidney  tuberculosis  before  extension  to  the 
other  kidney,  bladder,  ancl  genital  system,  the  removal  of  the  prostate 
would  have  still  wider  application  under  similar  conditions,  on  account 
of  the  diminished  relative  mortality  and  the  lessened  importance  of  the 
organ.  Excision  of  portions  of  the  prostate,  as  well  as  the  curetment  of 
tuberculous  ulcers  and  sinuses,  is  sometimes  employed. 

TUBERCULOSIS  OF  THE  SEMINAL  VESICLES 

Tuberculosis  of  the  seminal  vesicles  rarely  occurs  sa\'e  as  a  secondary 
extension  of  the  disease  from  other  portions  of  the  genito-urinary 
tract.  Instances  of  primary  involvement,  however,  have  been  reported 
in  connection  with  tuberculosis  of  the  bladder  and  prostate,  and  some- 
times of  the  epididymis.  The  symptoms  are  those  of  bladder  or  ure- 
thral irritability.  There  is  usually  marked  excitability  of  the  sexual 
organs,  and  not  uncommonly,  in  later  stages,  impotence  and  sterility. 
Cameron  and  others  have  called  attention  to  the  clinical  significance  of 
the  frequent  emissions  of  blood-stained  semen  in  such  cases.  I  have 
occasionally  observed  this  symptom  among  pulmonary  invalids  with- 
out detecting  physical  evidences  of  disease  of  the  seminal  vesicles. 

The  diagnosis  rests  upon  the  detection,  by  rectal  examination,  of 
hard,  rounded  protuberances  in  the  region  of  the  enlarged  vesicle. 
Tuholske  suggests  the  possibility  of  confusing  this  condition  with 
the  shot-like  masses  characteristic  of  phleboliths.     He  indorses  the 


506  COMPLICATIONS 

removal  of  the  vesicle  in  primary  cases  in  accordance  with  Zuckerkandl's 
operation,  which  consists  of  a  semilunar  incision  from  the  perineum  with 
the  base  downward.  This  procedure  is  indorsed  by  many  surgeons. 
In  the  event  of  coexisting  tuberculous  involvement  of  the  testicle  and 
vas,  necessitating  their  removal,  as  well  as  the  seminal  vesicles,  a  peri- 
neal incision,  following  the  removal  of  the  testicle  and  vas,  may  be 
made,  through  which  the  vesicle  may  be  pushed  from  the  rectum  and 
subsequently  extirpated.  According  to  Cameron,  Roux  reports  two 
such  cases.  "  Scraping  or  stripping  of  the  seminal  vesicle  is  sometimes 
practised,  but  its  propriety  relates  almo.st  entirely  to  a  primary 
involvement.  Bandet  and  Kendirdjy  have  recenth'  reviewed  46  cases 
of  extirpation  of  the  seminal  vesicle  and  vas.  The}-  regard  the  operation 
as  too  serious  to  justify  its  performance  save  in  the  presence  of  urinary 
fistula  from  tuberculosis  of  the  vesicle,  continuous  enlargement  of 
the  vesicle  with  existence  of  added  tutiercle  deposit  along  the  vas,  or 
rectal  obstruction. 


CHAPTER  LXXIV 
TUBERCULOSIS  OF  THE  EPIDIDYMIS  AND  TESTES 

Tuberculous  disease  of  these  parts  originates,  as  a  rule,  in  the 
epicUdymis  and  thence  extends  to  the  body  of  the  testes,  the  vas  deferens, 
and  the  seminal  vesicles.  The  involvement  of  the  epididymis  is  usually 
primary,  though  secondary  infection  sometimes  takea  place.  The 
circulation  is  the  almost  invariable  channel  of  infection,  but  it  is  possible 
that  the  entrance  of  bacilli  may  be  permitted  in  rare  instances  through 
the  urethra.  The  globus  major  is  the  part  first  involved  in  the  majority 
of  cases.  Attention  has  been  called  to  factors  of  some  etiologic  impor- 
tance, i.  e.,  the  small  size  and  extreme  tortuosity  of  the  arteries,  and 
the  division  of  the  spermatic  into  two  branches  in  close  proximity  to 
the  epididymis.  Immediate  continuity  of  structure  explains  the 
extension  of  the  disease  from  the  epididymis  to  the  testes,  although 
a  tuberculous  involvement  of  the  body  of  the  testes  rarely  ensues,  until 
tubercle  deposit  in  the  epididymis  has  attained  extensive  proportions 
and  undergone  caseation.  The  disease  is  not  infrequent  among  young 
adults,  and  is  observed  more  commonly  between  the  ages  of  twenty 
and  forty.  It  sometimes  exi.sts,  however,  in  very  early  life,  cases  hav- 
ing been  reported  even  in  infancy.  Several  observers  have  recorded 
cases  occurring  under  one  year. 

The  initial  macroscopic  pathologic  change  is  the  formation  of 
one  or  more  hard  nodules  in  the  globus  major.  These  increase  in  size 
until  the  entire  epididymis  assumes  the  characteristics  of  a  hard, 
nodular  growth.  The  mass  is  irregular,  knotty,  and  uniformly  solicl 
in  the  early  stages.  Following  the  period  of  depo.sit  and  initial  harden- 
ing, a  degenerative  pincc-s  ~uiicrvcnes  in  spots,  and  .some  of  the  nodules 
are  found  to  have  uii.l(r'.;(iiic  caseation  and  softening.  In  such  cases 
the  skin  speedily  luTdincs  adlierent  to  the  underlying  tissues,  and 
presents  a  peculiar  glistening  appearance  over  the  site  of  the  nodular 
softening.     In  these  locations  changes  in  color  also  take  place.     The 


TUBERCULOSIS   OF   THE    EPIDIDYMIS    AND   TESTES  507 

color  may  be  more  or  less  purplish  from  the  local  hj-peremia,  or  it 
may  assume  a  yellowish  appearance  from  the  abscess  formation  super- 
ficial to  the  surface,  with  impending  rupture  of  the  skin.  Perforation 
is  followed  by  the  chscharge  of  a  creamy,  yellowish  pus,  which  gradu- 
ally changes  to  a  thin,  cheesy  exudate.  These  tuberculous  sinuses  per- 
sist, as  a  rule,  indefinitely,  though  exhibiting  at  times  an  inclination 
toward  spontaneous  healing.  Tuberculous  involvement  of  the  vas  results 
in  a  thickening  throughout  its  course,  which  is  usually  more  pronounced 
at  its  extremities.  Hydrocele  is  often  present,  but  this  varies  according 
to  the  acuteness  of  onset,  upon  which  depends,  to  a  great  extent,  the 
character  of  the  clinical  symptoms. 

In  most  cases  the  condition  is  of  slow,  insidious  development,  and 
the  discovery  of  the  early  nodular  enlargement  of  the  epididymis  entirely 
accidental.  As  the  tubercle  deposit  assumes  larger  dimensions,  with  the 
formation,  in  the  epididymis,  of  a  tumor  of  wooden  hardness,  a  frequent 
distinguishing  characteristic  of  the  condition  is  noted  in  the  absence  of 
pain.  There  often  are  no  subjective  symptoms  manifested  aside  from  the 
sense  of  weight.  In  the.se  chronic  cases  the  tuberculous  process  is  almost 
always  unilateral,  and  attended  by  but  little,  if  any,  tendency  toward 
the  formation  of  hydrocele.  The  enlargement,  however,  may  progress 
with  considerable  rapidity  despite  the  absence  of  inflammatory  mani- 
festations. The  entire  organ  presents  the  characteristics  of  a  solid 
tumor,  uniformly  hard  in  consistency,  and  of  irregular  contour,  the  latter 
being  due  to  the  presence  of  nodular  protuberances  upon  the  surface. 
When  caseation  and  softening,  however,  have  taken  place  in  localized 
areas,  palpation  may  disclose  the  sharp,  crater-like,  overhanging  edges 
of  the  suppurating  nodule.  Examination  at  this  state  usually  reveals 
the  presence  of  tuberculous  infection  of  the  vas,  the  cord,  and  the 
seminal  vesicles.  Sinus  formation  is  also  a  very  important  characteristic 
of  tuberculous  involvement. 

An  acute  type  of  tuberculous  disease  of  the  epididymis  is  sometimes 
observed,  which  may  or  may  not  follow  the  history  of  trauma.  It  is 
easy  to  understand  how  slight  injury  to  these  parts  may  so  lower  the 
resistance  of  the  tissues,  as  to  bring  into  immediate  activity  an  infection 
previously  latent,  precisely  as  has  been  described  with  reference  to 
the  bones  and  joints.  Even  in  the  absence  of  traumatism,  however, 
tuberculosis  of  the  epididymis  may  develop  with  acute  symptoms  and 
pursue  a  rapid  course.  In  this  event  pain  is  pronounced  and  accom- 
panied .  by  a  peculiar  sickening  sensation.  An  early  formation  of 
hydrocele  is  the  rule  in  such  cases,  which  is  in  decided  contrast  to  the 
massive  caseation  exhibited  in  the  more  chronic  type  of  the  disease. 
When  of  more  or  less  acute  invasion  and  rapid  development,  the  process 
is  especially  likely  to  extend  to  the  opposite  .side.  In  such  cases  early 
abscess  formation  usually  occurs. 

Diagnosis. — An  essential  diagnostic  consideration  is  the  presence  of 
tuberculous  disease  in  other  portions  of  the  body,  and  especially  the 
location  of  demonstrable  lesions  in  some  part  of  the  genito-urinary 
system.  In  the  absence  of  discoverable  tuberculous  change  elsewhere 
important  diagnostic  data  relate  to  the  existence  of  a  solid  tumor 
originating  in  the  epididymis,  of  peculiar  hardness,  irregular  contour, 
possible  localized  areas  of  fluctuation,  aljsence  of  pain,  with  indurated 
profuse  nodular  thickening  of  the  vas  and  cord.  In  doubtful  cases  fail- 
ure to  respond  to  the  specific  therapeutic  test  is  of  considerable  value. 


508  COMPLICATIONS 

Gonorrheal  epididymitis  may  usually  be  excluded  by  the  history 
and  absence  of  previous  discharge  or  pain.  The  localized  areas  of 
caseation  and  softening,  with  tendency  to  sinus  formation,  are  dis- 
tinguishing features  in  the  tlifferentiation  from  sarcoma  or  syphilitic 
gumma.  The  latter  is  especially  prone  to  appear  in  the  testis,  while 
tubercle  deposit  usually  takes  place  in  the  epididymis,  before  the  testis. 

In  general  the  prognosis  maj'  be  said  to  depend  upon  the  health 
of  the  individual,  the  degree  of  implication  of  neighboring  structures, 
and  the  character  of  the  management.  Speaking  broadly,  the  prognosis 
should  not  be  considered  merely  with  reference  to  the  future  course  of 
the  tuberculous  organ,  but  also  as  regards  the  general  welfare  of  the 
patient.  Judged  by  this  latter  token  the  prognosis  must  depend  almost 
entirely  upon  the  nature  of  the  surgical  treatment,  which  of  necessity 
is  contingent  upon  the  general  health.  If  the  prognosis  is  unfavorable 
on  account  of  advanced  and  extensive  pulmonary  tuberculosis,  the  local 
condition  assumes  but  little  importance,  and  may  be  ignored  altogether 
in  the  management  of  the  case  other  than  in  so  far  as  pertains  to  palli- 
ative non-operative  measures.  In  such  concUtions  the  rational  surgical 
management  consists  merely  of  incision  and  drainage  of  infected  softened 
areas.  Local  cleanliness  must  be  secured  as  far  as  possible  in  the  hope 
of  avoiding  secondary  infection.  Several  cases  among  far-advanced  pul- 
monary invalids  under  my  observation  have  displayed  rather  remark- 
able improvement  in  the  general  condition  after  operation.  I  recall  one 
patient  whose  condition  was  regarded  as  extremely  desperate,  yet  sub- 
sequent incision  and  drainage  of  both  testicles  established  a  gain  of 
fifty  pounds  in  weight  during  the  course  of  the  ensuing  year.  Good 
results  are  sometimes  obtained  by  iodoform  applications  and  injections. 
The  employment  of  various  injections,  however,  into  the  thickened 
tissues  prior  to  the  stage  of  softening  is  unworthy  of  commendation. 

Treatment. — The  consideration  of  paramount  importance  in  tuber- 
culosis of  the  epidich'mis  and  testes  relates  to  the  expediency  of  castra- 
tion. This  alone  is  the  practical  issue  in  patients,  whose  general  health 
is  not  such  as  to  suggest  a  fatal  termination,  irrespective  of  the  local 
condition.  It  is  somewhat  remarkable  that  man}"  writers  persist  in 
advocating  extirpation  of  the  organ  only  after  general  and  non-opera- 
tive measures  have  proved  of  no  avail.  No  more  culpable  error  can  be 
perpetrated  than  to  dclai/  some  form  of  surgical  interference  in  young 
adults  with  unilateral  infection,  whose  pulmonary  involvement  is  of  such 
a  character  as  to  suggest  the  probability  of  ultimate  arrest.  Physicians 
who  endeavor  to  avoid  the  responsibilities  attending  early  excision  are 
committing  the  patient  to  the  possibility  of  double  infection  and  of 
extension  to  other  portions  of  the  genito-urinary  tract.  It  would  .seem 
almost  unnecessary  to  argue  that  a  broken-down  testis  and  epididymis 
can  be  of  no  possiiale  benefit  to  the  individual,  and  that  the  inunediate 
removal  in  toto  of  infected  tissue  is  indicated  upon  the  score  of  the  gen- 
eral health.  It  is  obvious  that  so  large  a  focus  of  tuberculous  infection 
as  a  caseated  testis  and  epididymis  must  constitute  a  distinct  menace  to 
the  life  of  the  patient.  A  reasonable  conclusion  is  to  the  effect  that 
there  is  absolutely  no  justification  for  the  long-continued  nursing  of 
the  affected  member.  Upon  the  other  hand,  its  prompt  extirpation  in 
appropriate  cases  provides  a  reasonable  assurance  of  protection  to  the 
opposite  side,  and  to  other  parts  of  the  genito-urinary  system.  Through 
the  elimination  of  a  large  tuberculous  focus,  added  opportunities  are 


TUBERCULOSIS   OF    THE    EPIDIDYMIS    AND   TESTES  509 

offered  for  the  arrest  of  the  pulmonary  disease.  In  cases  suitable 
for  surgical  interference  it  is,  of  course,  apparent  that  the  successful 
issue  depends  upon  the  time  0}  operation.  In  early  cases  with  the 
tuberculous  process  limited  to  the  epididymis  the  total  ablation  of 
the  testicle  is  seldom  necessary.  Under  such  circumstances  excision 
of  the  epididymis,  with  preservation  of  the  testicle,  is  the  operation  of 
choice.  If  the  vas  be  found  undiseased,  the  end  may  be  transplanted 
directly  into  the  body  of  the  testis.  In  this  event,  even  with  total 
removal  of  the  opposite  testis,  there  is  afforded  a  possible  preservation 
of  sexual  and  procreative  ability.  If,  however,  the  vas  is  found  to 
have  been  invaded  with  tuberculous  deposit,  it  should  be  resected  and 
tied  as  high  up  as  possible,  leaving  the  testis  by  itself  in  the  tunical  sac. 
This  presupposes,  of  cour.se,  that  the  body  of  the  testis  presents  no 
macroscopic  appearance  of  tuberculous  disease.  The  practice  of  total 
extirpation  of  the  epididymis  and  testis  by  reason  of  a  known  involve- 
ment of  the  former  and  a  presumptive  invasion  of  the  latter  is  sul)ject 
to  severe  condemnation.  A  sweeping  ablation  of  the  testis  ami  epi- 
didymis is  far  less  preferable  to  the  careful  dissection  of  the  epididymis 
as  a  preliminary  procedure,  even  though  the  extirpation  of  the  testis 
is  later  demanded.  The  preceding  operation  is  admittedly  more  tedi- 
ous, and  the  period  of  anesthesia  considerably  longer,  but  the  interests 
of  the  patient  are  in  many  instances  better  conserved.  This  method  of 
procedure  is  particularly  applicable  to  cases  of  early  involvement  of  the 
epididymis,  and  relates  with  special  emphasis  to  instances  6f  bilateral 
disease.  It  often  happens  that  while  the  indications  may  point  impera- 
tively toward  the  total  extirpation  of  the  epididymis  and  testis  upon 
one  side,  the  conditions  admit  of  at  least  the  preservation  of  the  testis 
upon  the  other.  Under  no  circumstances  should  double  castration  be 
performed  irrespective  of  the  degree  or  extent  of  the  pulmonary  disease. 
I  have  noted  several  instances  of  greatly  impaired  mentality  as  a 
result  of  this  operation.  Upon  the  other  hand,  I  have  observed  a 
notable  illustration  of  the  excellent  results  possible  of  attainment  from 
the  sacrifice  of  the  tuberculous  mass  upon  one  side  and  the  retention 
of  the  other  testis,  despite  the  removal  of  the  epididymis  and  vas.  The 
unfortunate  results  of  epididymectomy  are  quite  insignificant  in  com- 
parison with  the  deplorable  consequences  of  complete  castration.  The 
removal  of  the  epididymis  in  no  way  lessens  the  influence  of  the  inter- 
nal testicular  secretion  upon  the  general  health,  and  at  the  same  time 
does  not  detract  from  the  moral  effect  incident  to  the  preservation  of 
the  testis.  Examples  of  the  disastrous  consequences  of  delay  in  surgical 
interference  are  numerous.  I  will  cite  briefly  one  or  two  illustrative 
cases. 

Case  I. — A  married  man,  aged  thirty-two,  who  had  been  for  six 
years  the  subject  of  pulmonary  tiilierculosis,  consulted  me  early  in 
1907.  Although  the  arrest  of  the  tulierculous  process  in  the  lungs 
was  not  complete,  there  was  exhibited,  nevertheless,  but  little  remaining 
pulmonary  involvement.  The  general  condition  was  excellent,  nutri- 
tion was  well  maintained,  and  there  was  entire  absence  of  cough, 
expectoration,  or  temperature  elevation.  Five  weeks  previously  a 
small  nodule  had  been  felt  in  the  epididymis,  which  rapidly  increased 
in  size.  This  was  attended  by  some  pain,  although  the  recumbent 
position  was  maintained.  The  condition  grew  progressively  worse 
until  a  hard,  irregular,  nodular  mass  was  formed,  nearly  the  size  of 


510  COMPLICATIONS 

the  fist,  with  beginning  involvement  of  the  epididymis  of  the  opposite 
side.  There  was,  however,  no  evidence  of  local  softening.  The 
patient  coming  under  my  observation  at  this  time  and  objecting  to 
surgical  operation,  was  placed  upon  injections  of  bacilli  emulsion.  In 
addition,  efforts  were  directed  toward  superalimentation.  A  xxnju  of  a 
milligram  of  the  emulsion  was  immediately  administered,  and  repeated 
every  two  weeks  until  three  injections  had  been  given,  each  dose 
being  followed  by  a  perceptible  local  reaction.  During  the  month 
that  elapsed  an  appreciable  improvement  was  noted  in  the  general 
health,  and  a  diminution  in  the  size  of  the  large  tuberculous  organ. 
The  patient  gained  seven  pounds  in  weight,  local  pain  and  tender- 
ness entirely  disappeared,  without  evidence  of  increasing  involve- 
ment of  the  opposite  side.  There  shortly  developed,  however,  an 
abrupt  change  for  the  worse.  Caseation  and  softening  rapidly  took 
place  upon  the  side  first  involved,  together  with  an  acute  hard  enlarge- 
ment of  the  epididymis  upon  the  other.  The  opinion  of  a  surgeon 
was  rendered  unequivocally  as  to  the  imperative  necessity  of  double 
castration.  This  I  strenuously  opposed,  and  insisted  upon  an  attempt 
to  preserve,  if  possible,  the  body  of  the  testis  upon  the  side  recently 
affected.  This  operation  was  performed  by  Dr.  F.  L.  Dixon.  The 
tissues  of  the  left  side  were  totally  removed  because  of  the  advanced 
and  wide-spread  character  of  the  tuberculous  infection.  Upon  the 
right  side  the  epididymis  was  found  studded  with  tiny  tuberculous 
masses,  which  were  beginning  to  undergo  caseation.  The  body  of  the 
testis  was  apparently  uninvolved,  as  w^ell  as  the  vas.  After  excision 
of  the  epididymis  the  vas  was  transplanted  into  the  body  of  the  testis. 
Subsequent  to  the  operation  it  was  deemed  expedient  to  administer 
the  tuberculin  in  order  to  aid,  if  possible,  in  the  preservation  of  the 
remaining  testicle.  This  has  been  given  weekly  during  the  pa.st  six 
months,  and  the  patient  has  made  a  perfect  recovery,  sexual  desire  and 
potency  being  in  no  way  diminished. 

Case  II. — I  have  recently  had  under  my  care  a  man  of  twenty-nine 
years  whose  history  of  tuberculosis  dates  back  nine  years,  at  which 
time  he  exhibited  the  first  evidences  of  an  infection  of  the  epididymis. 
This  was  permitted  to  remain,  although  extensively  diseased,  during 
a  period  of  three  years.  It  was  then  removed,  but  not  until  he  had 
developed  tuberculous  involvement  of  the  bladder  and  one  kidney. 
The  patient  remained  under  my  observation  one  year,  and  in  addition 
to  well-defined  renal  tuberculosis,  has  been  compelled  to  suffer  the  pain 
and  cUscomfort  incident  to  advanced  infection  of  the  bladder,  prostate, 
and  seminal  vesicles.  His  general  condition  was  one  of  extreme  deliility, 
sufficient  to  preclude  the  expediency  of  surgical  interference  even  were 
this  permissible  upon  the  score  of  the  local  conditions.  There  has  been 
no  evidence  of  pulmonary  tuberculosis.  The  masterly  delay  in  surgical 
intervention  during  a  period  of  three  years  in  a  young  man  without 
evidence  of  pulmonary  tuberculosis  in  this  case  is  directly  responsible 
for  most  unfortunate  results,  and  is  a  striking  commentary  upon  the 
fallacious  teaching  relative  to  treating  patients  with  tuberculosis  of  the 
epididymis  and  testis  in  accordance  with  the  principles  appropriate  for 
pulmonary  tuberculosis.  Conspicuous  improvement  has  been  attained 
in  this  case  by  the  administration  of  the  bacilli  emulsion. 


TUBERCULOSIS    OF    THE    FALLOPIAN    TUBES 


CHAPTER   LXXV 

TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES,  UTERUS, 
AND  ADJACENT  STRUCTURES 

Tuberculous  involvement  of  the  Fallopian  tubes  is  exceedingly  com- 
mon. The  infection  of  the  tubes  is  often  primary,  but  may  take  place 
as  a  result  of  extension  from  a  neighboring  tuberculous  focus.  It  is 
probable,  as  stated  in  connection  with  the  general  etiology  of  tuberculo- 
sis of  the  genito-urinary  organs,  that  primary  involvement  of  the  tubes 
occurs  almost  as  frecjuently  as  of  the  epididymis,  and  perhaps  e^-en 
more  often  than  of  the  prostate.  The  origin  of  the  tuberculous  proc- 
ess may  be  traced,  in  the  majority  of  instances,  to  an  infection  con- 
veyed by  the  circulation.  It  is  uncertain  to  what  extent  the  lym- 
phatics act  as  carriers  of  the  bacilli.  It  is  possible  that,  in  rare 
instances,  infection  may  take  place  as  a  result  of  coitus  with  a  tuber- 
culous invalid.  It  is  more  than  likely,  however,  that  this  manner  of 
bacillary  invasion  of  the  female  genital  tract  occurs  but  exception- 
ally. Admitting  such  possibility,  however,  it  still  remains  highly 
improbable  that  a  suitable  lodging-place  for  the  bacilli  is  afforded  in  the 
vagina,  on  account  of  the  natural  fortifications  of  this  region.  Pro- 
tection is  afforded,  first,  by  the  tough  squamous  epithelium,  the  non- 
eroded  surface  of  the  mucous  membrane,  and  the  profuseness  of  the 
mucous  secretions,  which  are  usually  highly  acid  in  reaction.  Although 
tubercle  bacilli  are  sometimes  found  in  the  vagina,  a  genuine  tubercu- 
lous process  in  this  region  is  relatively  infrequent.  When  this  does 
exist,  it  occurs  almost  always  in  conjunction  with,  and  secondary  to, 
tuberculosis  of  the  Fallopian  tubes,  the  uterus,  or  of  both.  It  may  be 
accepted  as  an  almost  universal  fact  that  tuberculosis  of  the  female 
genital  system,  other  than  the  occasional  existence  of  lupus  of  the 
external  genitalia,  has  its  primary  origin  in  the  tubes.  From  such 
point  of  departure  secondary  deposits  may  take  place.  Hare  refers  to 
the  statistics  of  eight  European  pathologists  in  illustration  of  the  great 
frequency  of  tuberculosis  of  the  female  genital  tract.  Tuberculous 
involvement  of  the  genitals  was  found  at  autopsy  208  times  out  of 
8627  cases  of  tuberculosis  in  females.  According  to  Cornet,  Kiwisch 
found  the  proportion  of  involvement  in  similar  cases  to  be  one  in  forty, 
and  Cornil  in  one  to  fifty  or  sixty. 

Tuberculous  disease  of  these  parts  may  exist  at  any  time  of  life,  though 
it  is  more  frequent  at  the  period  of  greatest  sexual  activity.  Many  cases 
of  its  occurrence  have  been  reported,  however,  among  young  children. 
Gusserow  has  cited  a  cusenf  tuberculous  di.sease  in  the  ovaries  and  uterus 
at  this  time  of  life,  wit  I  unit  im|ilirution  of  the  tubes.  ^Bender  has  collected 
a  record  of  48  ca.ses  of  t  uhorculosis  of  the  vulva,  exhibiting  ulcerative  and 
hypertrophic  lesions.  Some  of  these  were  undoubtedly  influenced  in 
their  development  by  trauma.  From  the  statistical  observations  thus  far 
reported  it  may  be  assumed  that  the  lungs  are  diseased  in  at  least  one- 
half  of  the  cases  of  genital  tuberculosis,  and  some  other  portion  of  the 
urinary  system  in  about  the  same  proportion  of  cases. 

The  gross  pathologic  change  in  tuberculosis  of  the  Fallopian  tubes 
consists  of  a  thickened,  indurated  condition  of  the  wall.  This  is  asso- 
ciated with  a  collection  of  cheesy  pus,  somewhat  after  the  manner  of 


512  COMPLICATIONS 

ordinary  pyosalpinx.  The  abscess  formation  takes  place  almost  always 
at  some  point  in  the  tube  more  or  less  remote  from  either  extremity. 
The  fimbriated  end  usually  becomes  thickened  and  adherent  to  the 
ovary  or  the  peritoneum,  producing  a  permanent  occlusion  of  the  lumen. 
Obliteration  of  the  canal  often  takes  place  also  at  its  proximal  end, 
and  this  suffices  in  many  cases  to  prevent  the  escape  of  infected  cheesy 
detritus  into  the  uterus.  The  intervening  portion  of  the  tube  is  usually 
somewhat  dilated,  and  in  some  cases  becomes  the  seat  of  miliary  nodules. 
In  the  event  of  uterine  infection,  the  tuberculous  process  commonly 
begins  in  the  vicinity  of  the  tubal  orifices,  the  cervix  seldom  being 
involved.  Tuberculosis  of  the  uterus  has  been  regarded  in  the  past  as 
a  very  rare  condition,  but  is  undoubtedly  somewhat  more  frequent  than 
was  formerly  supposed.  The  process  makes  its  fii-st  appearance  in 
the  endometrium,  which  becomes  infiltrated  with  tubercle  deposit. 
Caseation,  softening,  and  coalescence  of  these  lesions  produce  an  ulcer- 
ative endometritis  in  the  discharge  of  which  tuliercle  Isacilli  are  some- 
times found.  The  disease  may  extend  from  the  distal  end  of  the  tube 
to  the  ovary  or  peritoneum.  The  former  may  become  studded  with 
tuberculous  nodules  or  break  down  into  an  abscess  cavity.  Evidences 
of  localized  peritonitis  sometimes  follow  the  invasion  of  the  serous  mem- 
brane in  the  immediate  neighborhood  of  the  fimbriated  end  of  the  tube. 

The  symptoms  of  tuberculosis  of  the  tube  in  some  cases  do  not  differ 
from  those  of  onlinary  catarrhal  salpingitis,  but  there  may  be  in  other 
instances  characteristic  evidences  of  p3-osalpirLx.  The  condition  is 
usually  bilateral.  Upon  palpation  alone  it  is  difficult  to  differentiate 
tuberculosis  of  the  tube  from  other  pathologic  conditions  producing 
tumor  in  this  region. 

The  symptoms  of  tuberculosis  of  the  uterus  are  not  especially  dis- 
similar to  those  of  non-tuberculous  endometritis.  There  may  be 
temperature  elevation  and  evidence  of  moderate  septic  infection,  with, 
usually,  tenderness  and  some  enlargement.  The  character  of  the 
involvement  is  suggested  by  the  recognition  of  tuberculous  disease 
in  other  parts  of  the  body,  and  confirmed  by  the  detection  of  tubercle 
bacilli  in  the  uterine  discharge.  In  the  event  of  a  negative  history  of 
tuberculosis  and  failure  to  discover  an  infection  in  other  regions,  the 
nature  of  the  involvement  may  be  disclosed  by  the  presence  of  bacilli 
in  the  discharge,  or  by  a  microscopic  examination  of  the  uterine  mucosa 
removed  by  the  curet. 

In  the  absence  of  active  and  extensive  pulmonary  disease,  the 
prognosis  depends  upon  the  early  recognition  of  the  condition  and  the 
adoption  of  prompt  surgical  measures.  The  diagnosis  once  established, 
there  should  be  no  dela}-  in  o])erative  interference  among  patients  whose 
general  condition  does  not  cimtraindicate  surgical  aid. 

The  treatment  is  purely  sure,ical,  and  consists  of  vaginal  hysterec- 
tomy, with  removal  of  tubes  and  ovary  if  infected. 

It  is  important,  even  in  woman,  to  ascertain  conclusively  in  regard 
to  the  condition  of  the  kidneys  and  urinary  tract  in  cases  of  genital 
tuberculosis.  Kelly  has  recently  called  attention  to  the  rather  sur- 
prising association  between  renal  tuberculosis  and  a  similar  involvement 
of  the  tubes  and  uterus.  The  treatment  of  lesions  involving  the  external 
genitals  is  that  of  free  and  wide  excision,  or  tentative  recourse  to  tuber- 
culin injection. 


TUBERCULOSIS    OF    THE    SKIN 


SECTION   VIII 


Tuberculosis  of  the  Skin  and  Upper  Respiratory 
Tract 


CHAPTER   LXXVI 
TUBERCULOSIS  OF  THE  SKIN 

Genuine  tuberculous  involvement  of  the  cutaneous  tissue  is  rare 
among  phthisical  patients,  but  nevertheless  of  exceeding  interest. 
Tuberculous  lesions  of  the  slcin  occur  among  individuals  otherwise 
healthy,  but  some  of  the  clinical  varieties  are  found  with  greater  fre- 
quency among  patients  suffering  from  tubercle  deposit  in  other  parts  of 
the  body.  Illustrative  of  this,  is  the  well-known  relation  of  the  ulcera- 
tive form  of  tuberculosis  cutis  to  infective  processes  in  the  nasal  cavities 
and  to  lesions  of  the  genito-urinary  tract.  The  uniform  proximity  of 
.certain  types  of  tuberculous  skin  lesions  to  the  mucous  orifices,  viz., 
of  the  mouth,  nose,  vagina,  and  rectum,  is  presumptive  evidence  of 
an  infection  derived  from  these  respective  avenues,  despite  the  absence  of 
demonstrable  tuberculous  processes  in  parts  tributary  to  the  openings. 

Other  clinical  forms  of  cutaneous  tuberculosis  suggest  a  source  of 
infection  from  without  the  body,  either  as  a  result  of  contagion  or 
accidental  inoculation.  This  is  especially  true  of  the  verrucous  tj'pe  of 
skin  infection,  the  verruca  necrogenica,  or  so-called  anatomic  wart,  the 
verruca  cutis,  believed  by  many  to  be  identical  with  the  preceding,  and, 
lastly,  lupus  verrucosa. 

Still  other  varieties  owe  their  origin  to  contiguity  of  structure,  par- 
ticularly the  scrofuloderma,  which  results  by  extension  from  adjacent 
tuberculous  glands  or  an  underlying  infection. 

Finally,  the  local  condition  may  arise  from  a  dissemination  of  the 
infection  through  the  circulation,  the  integument  becoming  affected 
as  a  result  of  the  conveyance  of  bacilli  from  some  internal  focus.  It  is 
likely  that  certain  forms  of  lupus  originate  in  this  manner,  and  par- 
ticularly   the    tuberculosis   disseminata. 

Waiving  for  the  time  being  any  discussion  regarding  the  clinical 
aspects  of  these  types  of  cutaneous  lul>('rcul(i,~is,  altcntion  is  directed 
to  the  role  of  the  skin  as  a  chavnd  fur  lulu  i-ciilmis  infection.  This  is 
perhaps  of  gi-eater  scientific  interest  than  tlie  local  manifestations  of 
the  tuberculous  condition.  It  is  to  be  remembered  that  a  localized 
tuberculosis  of  the  integument  affords  no  evidence  in  favor  of  the  skin  as 
a  port  of  entry  for  the  initial  tuberculous  invasion.  Local  processes, 
however,  may  be  expected  to  attend  an  entrance  of  the  infection  through 
the  skin.  It  has  been  claimed  by  some  observers  that  whenever  the 
skin  constitutes  the  avenue  of  infection,  the  tuberculous  deposit  is 
confined  to  the  integument,  and  remains  a  distinctly  localized  process. 
This  is  unsupported  by  clinical  data,  although  in  many  instances  the 
advance  of  the  baciUi  is  arrested  by  the  proximal  lymphatic  glands. 
The  virulence  of  the  infection  following  inoculation  is  usually  slight. 


514  COMPLICATIONS 

Its  progress  in  the  lymphatic  channels  is  more  or  less  obstructed,  and 
the  evolution  of  tuberculous  lesions  of  the  skin  exceedingly  slow. 
The  difficult  genesis  of  cutaneous  tuberculosis  is  explained  by  the 
unfavorable  character  of  the  soil.  The  thickened  epithelium,  especially 
in  certain  localities,  offers  a  protective  barrier  against  tuberculous 
infection,  even  though  exposure  be  excessive  and  long  continued. 
Further,  the  temperature  is  usually  insufficient  for  the  growth  of  bacilli, 
even  in  the  event  of  direct  inoculation  into  the  subcutaneous  tissue. 
After  the  actual  development  of  tuberculous  skin  lesions  the  number 
of  bacilli  are  few  in  comparison  with  similar  processes  in  the  internal 
organs. 

In  1898  Baldwin  demonstrated  the  presence  of  living  tubercle 
bacilli  upon  the  hands  of  pulmonary  invalids.  He  poured  over  the 
palmar  surface  of  the  fingers  from  5  to  10  c.c.  of  a  sterilized  1  per  cent, 
solution  of  NaCO^,  using  sterilized  plain  glass  finger-bowls  as  receptacles. 
The  washings  were  inoculated  into  guinea-pigs,  with  a  positive  result 
in  10  out  of  15  cases.  Tubercle  bacilli  were  also  found  in  the  micro- 
scopic examination  of  the  centrifuged  sediment  in  2  cases.  Somewhat 
similar  results  had  been  obtained  by  Cornet  in  the  previous  year.  In 
connection  with  these  experiments  it  is  interesting  to  consider  the 
much  greater  exposure  of  the  lips.  Important  considerations  are  the 
lessened  protection  arising  from  the  relative  delicacy  of  the  tissues, 
the  common  existence  of  fissures  upon  the  mucous  surface,  and  yet  the 
infrequency  of  local  lesions  among  a  class  of  people  compelled  dailj^  to 
expectorate  enormous  numbers  of  bacilli.  Even  in  this  location 
resulting  lesions,  if  present,  are  almost  alwaj's  indolent. 

There  are  recorded  numerous  instances  of  the  limitation  of  the 
tuberculous  process  upon  the  hands  following  contamination  with 
infected  material  and  accidental  inoculation.  Even  after  intrnckiction 
directly  into  the  subcutaneous  tissues,  the  infective  material  is  usually 
discharged  by  suppuration,  or  the  resulting  tumor  disappears  by 
resolution  without  clinical  evidences  of  further  infection.  The  resis- 
tance to  infection  by  the  skin  is  also  demonstrated  by  experiments 
upon  the  lower  animals. 

It  is  well  to  refer  to  some  of  the  cKnical  and  experimental  data 
upon  which  is  based  the  assumption  of  a  definite  localization  of  the 
tuberculous  process,  either  upon  the  integument  or  at  most  in  the  proxi- 
mal lymphatic  glands.  The  evidence  as  to  the  comparatively  innocuous 
character  of  the  infection  relates — (1)  To  the  development  of  lesions 
upon  the  hands  of  individuals  after  exposure  by  contact  with  tubercu- 
lous meat;  (2)  similar  processes  involving  the  skin  of  pathologists 
following  postmortem  examinations  of  human  and  animal  subjects; 
(3)  instances  of  accidental  penetration  of  the  bacilli  through  the  skin 
of  those  thrown  into  clo.se  association  with  consumptives,  or  accustomed 
to  handle  infectious  sputum;  (4)  the  attempted  cutaneous  inoculation 
of  animals  with  subcutaneous  or  intraperitoneal  injections  in  control 
animals,  (5)  ineffective  inoculation  of  unfortunates  suffering  from 
malignant  non-operable  disease.  These  several  considerations  may  be 
briefly  discussed  seriatim. 

The  infection  of  the  hands  after  exposure  to  contact  with  tuberculous 
meat  is  always  a  strictly  localized  condition.  Lozzar,  in  190.3,  exhibited 
a  number  of  such  cases,  in  which  there  had  taken  place  no  extension  of 
the  tuberculous  process  beyond  the  point  of  infection,  although  the 


TUBERCULOSIS    OF    THE    SKIN  515 

local  lesions  had  existed  for  many  years.  If  it  be  assumed  that  general 
dissemination  of  the  infection  takes  place  from  the  site  of  inoculation 
in  such  cases,  it  must  follow  that  butchers,  before  the  days  of  meat 
inspection,  would  have  shown  a  relatively  high  mortality  rate  from 
tuberculosis.  This  has  not  been  demonstrated  to  be  the  case.  Von 
Ruck  has  called  attention  to  the  observations  of  Heilburg,  who  reported 
an  average  of  618  butchers  in  Copenhagen  with  but  25  deaths  from 
tuberculosis  during  a  period  of  ten  years. 

During  recent  years  numerous  instances  have  been  reported  of  an 
apparently  benign  local  infection  following  small  abrasions  of  the 
skin,  or  accidental  injury  during  autopsy  upon  man  and  animals.  A 
conspicuous  example  of  the  non-virulent  character  of  such  local  infec- 
tion is  found  in  the  experience  of  Laennec,  who  suffered  an  accidental 
inoculation  while  performing  an  autopsy,  and  survived  twenty  years, 
though  finally  dying  of  phthisis  attributed  by  some  to  the  original 
local  invasion.  Gerber's  case  is  also  of  interest.  Following  an  autopsy 
wound,  and  in  spite  of  immediate  disinfection,  a  "Leichen"  tubercle 
the  size  of  a  cherry  developed  at  the  site  of  the  injury,  and  persisted 
for  months.  Shortly  after  excision  of  the  nodule  the  axillary  glands 
became  involved,  and  when  extirpated  were  found  to  contain  tubercle 
bacilli  and  to  present  characteristic  tissue  changes.  There  were  no 
evidences  of  further  tuberculous  extension. 

Many  isolated  cases  of  injury  during  autopsy  upon  consumptives 
could  be  cited  to  support  the  contention,  made  by  the  advocates  of  a 
limited  benign  tuberculous  process,  that  the  infection  is  either  confined 
to  the  site  of  inoculation  or  is  arrested  by  the  nearest  lymphatic  glands. 
Extension  by  means  of  the  lymphatics  is  more  frequent  in  case  of  the 
anatomic  wart  following  autopsy  upon  the  human  subject,  than  in 
association  with  the  local  lesions  upon  the  hands  of  those  exposed  to 
contact  with  tuberculous  meat,  viz.,  the  verruca  cutis  described  by 
Riehl  and  Paltauf. 

Accidental  inoculation  occasionally  results  from  autopsies  upon 
tuberculous  cows,  and  cases  have  been  reported  of  this  occurrence 
without  secondary  extension  of  the  infection.  Ravenel  has  cited  four 
cases  of  local  tuberculous  change  following  a  skin  wound  upon  the  hands 
of  veterinarians  during  postmortem  examination.  In  no  instance  was 
there  an  extension  of  the  process  even  to  the  nearest  lymphatic  glands, 
although  the  growth  of  the  nodule  at  the  seat  of  inoculation  was  very 
rapid  in  one  or  two  cases,  suggesting  a  decided  virulence  of  the  infection. 
In  the  first  case  reported  the  diagnosis  was  based  upon  the  clinical 
history  and  the  histologic  lesions,  bacilli  not  being  demonstrated  in  the 
sections.  In  the  second  case  the  local  lesion  developed  at  the  expiration 
of  three  weeks  after  injury.  The  nodule  was  excised  two  months  after 
the  initial  skin  abrasion,  and  two  guinea-pigs  were  inoculated  sub- 
cutaneously,  with  positive  results.  In  the  third  case  the  local  process 
developed  at  the  expiration  of  nearly  four  weeks  after  the  accident.  The 
nodule  was  excised  at  the  end  of  six  weeks,  and  tubercle  bacilli  were 
found  in  the  sections.  In  his  report  of  the  fourth  case  local  symptoms 
were  described  as  appearing  in  about  four  weeks,  with  a  well-de\eloped 
nodule  within  six  weeks.  Two  guinea-pigs  inoculated  with  portions 
of  the  nodule  developed  generalized  tuberculosis,  and  tubercle  bacilli 
were  found  upon  examination  of  other  portions  of  the  growth. 
Tscherning  has  reported  a  case  of  accidental  injury  to  the  hands  of  a 


516  COMPLICATIONS 

veterinary  surgeon  occurring  at  autopsy.  The  process  was  essentially 
local,  though  attended  by  slight  extension  through  the  lymphatics. 
Ravenel  has  referred  to  the  experience  of  Mueller,  who  describes  two 
cases  of  injury  to  the  fingers  resulting  during  work  upon  tuberculous 
cattle.  In  each  case  the  synovial  sheath  of  a  tendon  was  opened. 
After  operation  there  was  found  a  distinct  tuberculous  deposit  upon 
the  wall  of  the  sheath,  and  U])cin  the  tendon  in  immediate  proximity 
to  the  site  of  the  wound,  in  one  rase  extending  not  over  a  distance  of 
10  centimeters,  and  in  the  other  merging  into  the  forearm.  Ravenel 
further  alludes  to  one  case  observed  by  de  Jong,  and  to  two  reported 
by  Joseph  and  Trautman,  in  all  of  which  the  tuberculous  lesion  resulted 
from  injury  received  while  at  work  upon  tuberculous  cows,  and  was 
confined  to  the  point  of  inoculation  in  each  instance.  A  similar  case 
is  reported  by  Braquehaye. 

Penetration  of  the  sldn  of  individuals  by  tubercle  bacilli  of  human 
origin  is  not  uncommon  as  a  result  of  accidental  injury.  Numerous 
cases  of  such  inoculation  have  been  observed  among  nurses,  attendants, 
relatives,  and  domestics  thrown  into  close  association  with  pulmonary 
invalids  and  with  tuberculous  products.  According  to  Cornet,  cases 
have  been  reported  by  Tscherning,  Merklen,  Lesser,  and  Hoist,  in  which 
the  wound  was  received  through  contact  with  a  broken  edge  of  a  cuspidor 
or  glass  sputum  cup,  the  local  process  being  followed  by  involvement 
of  the  lymphatic  glands. 

I  have  under  observation  at  the  present  time  a  case  which  presents 
features  of  unusual  interest.  The  patient  is  a  woman  of  forty-five 
years  who  has  been  employed  as  a  servant  during  the  past  ten  years 
in  a  large  and  well-known  institution  for  consumptives.  Throughout 
this  entire  period  her  work  has  consisted  of  the  very  frequent  handling 
of  cuspidors.  Some  three  years  ago  she  developed  an  advanced  tuber- 
culous tenosynovitis  or  compound  ganglion  at  the  front  of  the  right 
wrist.  This  extended  down  the  sheaths  of  the  tendons  of  the  little  and 
index  fingers  nearly  to  the  tips.  A  physician  recently  opened  the 
swelling  at  the  middle  of  the  little  finger,  squeezing  out  the  so-called  rice- 
bodies.  From  day  to  daj-  more  or  less  of  these  were  expresseil.  The 
little  finger  becaiiie  infected  through  the  wound,  and  the  infection 
spread  up  the  sheath  of  the  tendon  to  the  general  bursa  at  the  front  of 
the  wrist  and  thence  to  the  index  tendon.  In  view  of  the  acute  septic 
manifestations  which  supervened,  it  was  necessary  to  amputate  the 
little  finger,  to  excise  its  flexor  tendon,  and  to  lay  open  and  drain  the 
compound  ganglion  itself,  as  well  as  the  sheath  of  the  index  flexors. 
Diligent  attention  by  Dr.  Powers  saved  the  hand  proper. 

Instances  of  local  infection  are  reported  by  Cornet  to  have  taken 
place  as  the  result  of  a  bite  by  a  consumptive  (\'erchere,  Jeanselme, 
Leloir).  Other  cases  of  accidental  injury  of  various  kinds,  with  sub- 
sequent local  lesions,  are  recorded  among  attendants  upon  consumptives 
and  even  among  pulmonary  invalids  tlicinMlxcs.  Local  cutaneous 
tuberculosis  is  found  occasionally  amoiiu  l.iiiii^li(<-es  accustomed  to 
handle  the  linen  of  consumptives.  It  has  l)een  known  to  result  from 
the  piercing  of  ears  and  the  wearing  of  infected  earrings.  Czerny  is 
authority  for  two  cases  resulting  from  skin-grafting.  Ulcerative 
tuberculous  lesions,  especially  of  the  face,  are  not  infrequently  traced 
to  slight  abrasions  of  the  skin  in  consumptives  or  others  exposed  to  an 
obvious  source  of  infection.     In  occasional  instances  the  same  is  true 


TUBERCULOSIS    OF    THE    SKIN  517 

of  the  external  genitals.  Under  such  circumstances  lupoid  changes 
have  supervened  at  the  site  of  unhealed  sores,  incised  or  punctured 
wounds,  and  almost  all  forms  of  excoriation  upon  the  skin,  including 
eczematous  and  vaccination  surfaces. 

Animal  experimentation  has  also  been  instructive  in  determining 
the  role  of  the  skin  as  a  port  of  entry  of  general  tuberculous  infection. 
Calves,  sheep,  swine,  goats,  and  guinea-pigs  were  made  the  subject 
of  investigation  by  Chaveau,  Giinther,  Horner,  and  Bollinger  in  former 
years.  Laboratory  experiments  conducted  upon  animals  in  the  effort 
to  produce  a  cutaneous  inoculation  with  highly  virulent  human  bacilli 
were  frequently  unsuccessful.  In  like  manner  negative  results  have 
followed  similar  attempts  to  infect  these  animals  by  means  of  subcuta- 
neous or  intraperitoneal  inoculations,  with  the  single  exception  of  the 
guinea-pig,  which  is  the  most  susceptible  of  the  entire  animal  species. 
Bollinger  was  unable  to  produce  infection  through  the  skin  of  the 
guinea-pig  in  a  series  of  six  experiments,  but  was  successful  in  the  sub- 
cutaneous  injections  of  the  control  animals.  Baumgarten,  in  1901, 
reported  work  done  in  his  institute  by  Gaiser  in  connection  with  experi- 
ments upon  calves  with  human  tubercle  bacilli.  It  was  found  that  after 
subcutaneous  injections  of  large  numbers  of  bacilli  from  pure  culture, 
the  point  of  inoculation  remained  almost  without  reaction,  and  when 
the  animals  were  killed,  several  months  later,  no  trace  of  tuberculous 
change  existed  in  any  part  of  the  body.  These  results  closely  con- 
formed to  those  obtained  by  Koch,  who  inoculated  young  cattle  with 
pure  cultures  of  tubercle  bacilli  taken  from  human  beings  without  dis- 
covering subsequent  symjitoms  of  disease  or  the  slightest  evidence  at 
autopsy  of  pathologic  change.  A  somewhat  doubtful  result  of  inocula- 
tion experiment  was  reported  by  de  Schweinitz,  Dorset,  and  Schroeder. 
A  heifer  was  inoculated  with  a  portion  of  lung  and  intestine  from  a 
human  subject  dead  of  miliary  tuberculosis.  After  six  months  an 
autopsy  was  performed  and  a  small  abscess  found  at  the  point  of  injec- 
tion. Tuberculous  involvement  of  proximal  lymphatic  glands  was  dis- 
covered, and  indeterminate  growths  upon  the  pleura  and  diaphragm. 

The  relation  of  human  to  bovine  tuberculosis  necessarily  involved 
in  these  and  other  experiments  has  been  discussed  at  some  length,  hence 
further  reference  to  this  relationship  will  be  made  as  brief  as  possible. 

Previous  to  the  investigations  of  Koch  and  Baumgarten,  Rokitansky 
had  endeavored  in  vain  to  produce  an  infection  in  human  beings  suffering 
from  incurable  disease.  Bovine  tubercle  bacilli  were  employed  in  these 
ineffective  inoculations  because  they  had  been  found  highly  virulent 
for  rabbits,  and  were  supposed  to  be  identical  with  the  type  of  micro- 
organisms derived  from  human  tuberculosis.  After  a  dozen  trials 
without  resulting  infection  the  experiment  was  abandoned,  and  no 
attempts  of  a  similar  character,  as  far  as  I  have  been  able  to  ascertain, 
have  been  repeated. 

The  foregoing  considerations  comprise  a  portion  of  the  evidence 
which,  from  time  to  time,  has  been  regarded  as  sufficient  to  justify  the 
belief  in  a  cutaneous  infection  which  is  almost  invariably  localized  and 
benign.  Ravenel,  in  his  contention  for  the  intercommunicability  of 
bovine  and  human  tuberculosis,  explains  the  innocuous  character  of 
the  lesions  produced  by  accidental  inoculation  with  bovine  tubercle 
bacilli,  by  assuming  an  equally  benign  local  process  resulting  from 
infection  with  human  bacilli.     This  again  introduces  the  question  of 


518  COMPLICATIONS 

differences  between  these  two  varieties  of  bacilli,  and  also  suggests  the 
presentation  of  data  to  disprove  a  frequent  limitation  of  the  tuberculous 
process  at  the  site  of  inoculation,  irrespective  of  the  special  type  of 
tubercle  bacilli.  Attention  is,  therefore,  directed  once  more  to  the 
cutaneous  lesions  appearing  upon  the  hands,  derived  from  tuberculous 
meat  and  the  cadavers  of  man  and  animals,  or  from  inoculation  with 
infected  material  through  contact  with  tuberculous  sputum,  and  also 
to  different  experiments  upon  animals  with  the  human  and  bovine 
bacilli. 

The  verrucous  variety  of  tuberculous  lesions  of  the  skin  may  be 
accepted  as  the  most  frequent  manifestation  of  the  local  infection. 
Admittedly  this  form  of  cutaneous  tuberculosis  is  rarely  accompanied 
by  evidence  of  lymphatic  involvement,  although  superficial  extension 
does  take  place  in  many  instances.  The  process,  though  insignificant 
at  first,  may  spread  rapidly  upon  the  surface  of  the  integument  from  the 
point  of  invasion  until  several  inches  are  embraced  within  the  diseased 
area.  The  necrogenic  wart,  the  common  form  of  autopsy  lesion,  though 
more  localized  in  the  cutaneous  tissues  than  the  verrucous  type,  is  more 
often  accompanied  by  secondary  extension,  and  sometimes  even  by 
grave  systemic  infection.  A  case  in  point  is  the  recent  observation  by 
Ransome  (Walsham),  concerning  the  development  of  acute  symptoms 
following  an  injury  to  the  left  hand  of  a  physician  while  performing  an 
autopsy  upon  a  child  who  had  died  of  tuberculous  peritonitis.  Six 
days  later  the  temperature  rose  to  103°  F.,  and  a  small  localized  pneu- 
monic consolidation  was  detected  at  the  base  of  the  left  lung.  Shortly 
afterward  the  left  axillary  glands  exhibited  evidence  of  invasion. 
Two  weeks  after  the  injury  the  swelling  of  glands,  together  with  the 
constitutional  disturbance,  was  sufficient  to  demand  measures  for 
surgical  relief.  After  incision  the  pus  was  found  to  contain  tubercle 
bacilli,  and  was  infective  to  guinea-pigs  in  three  weeks.  Cases  of 
secondary  involvement  of  glands,  pulmonary  infection,  and  finally 
death  have  been  reported  by  Verneuil,  \'erchere,  Pich,  and  Pfeiffer 
(Cornet).  I  am  personally  cognizant  of  a  similar  case  of  autopsy  infec- 
tion to  which  a  former  colleague  succumbed. 

The  physician,  previously  in  robust  health,  suffered  a  slight  injurj^ 
to  the  thumb  from  the  breaking  of  a  slide  while  examining  tuberculous 
sputum.  There  shortly  developed  a  sore  upon  the  thumb,  character- 
istic of  the  verrucous  form  of  cutaneous  tuberculosis.  Amputation  of 
the  thumb  was  advised,  but  refused.  In  spite  of  involvement  of  the 
proximal  lymphatic  glands,  the  sore  healed  in  from  a  month  to  six 
weeks.  After  a  few  months  an  idiopathic  pleurisy  developed,  which 
sub.sequently  proved  to  be  of  tuberculous  nature.  He  died  of  pulmonary 
tuberculo-i-  in  t  \y<<  yoars  from  the  time  of  the  injury. 

It  is  |i  .--ililr  that  such  cases  would  be  more  numerous  were  it  not 
for  the  piutcctidii  afforded  by  the  bleeding,  and  the  prompt  measures 
toward  disinfection.  Deneke  has  recorded  a  case  of  localized  cutaneous 
tuberculosis,  followed  by  infection  of  the  cervical  lymphatics  and  death 
in  a  child.  The  injury  was  occasioned  from  a  broken  jar  used  by  a 
tuberculous  mother.  Instances  of  a  fatal  termination  from  accidental 
inoculation  with  bovine  baciUi  are  also  recorded.  Hartzell  reported 
the  development  of  the  verrucous  type  of  cutaneous  lesion,  followed  by 
death  from  pulmonary  tuberculosis  within  one  year.  Pfeiffer  has  related 
the  case  of  a  veterinary  surgeon,  who  exhibited  a  definitely  localized 


TUBERCULOSIS    OF    THE    SKIN  519 

tuberculosis  of  the  cutaneous  tissues,  yet  who  succumbed  to  consump- 
tion at  the  end  of  one  and  one-half  years  after  the  injury.  Ravenel  has 
cited  the  death  of  Mr.  Thomas  Walley,  Principal  of  the  Royal  Veterinary 
College  of  Edinburgh,  as  a  probable  instance  of  infection  received  during 
autopsy  upon  a  tuberculous  cow. 

The  experiments  upon  animals  by  Baumgarten  and  Koch,  which 
have  been  described,  were  accompanied  by  similar  inoculation  of  calves, 
swine,  asses,  sheep,  and  goats  with  the  use  of  bovine  bacilli.  In  the 
first  calf  infected  by  Baumgarten,  death  took  place  within  six  weeks 
from  general  miliary  tuberculosis  attended  with  great  emaciation  and 
dyspnea.  The  investigations  of  Koch  with  bovine  bacilli  yielded  almost 
identical  results.  Injections  of  tubercle  bacilli  taken  from  the  lungs  of 
cattle  with  advanced  pulmonary  tuberculosis  were  made  subcutaneously. 
After  a  brief  period  there  developed  high  fever  and  progressive  emacia- 
tion. Many  died  after  the  lapse  of  one  or  two  months.  At  autopsy, 
characteristic  changes  were  found  not  only  at  the  site  of  inoculation, 
but  also  in  the  lymphatic  glands,  lungs,  spleen,  omentum,  and  peri- 
toneum. 

Since  the  report  of  these  early  experiments  much  investigation  of 
a  similar  nature  has  been  conducted  by  European  and  American 
observers.  It  has  been  pointed  out,  in  connection  with  the  relation 
of  human  and  bovine  tuberculosis,  that  tubercle  bacilli  of  human  origin 
have  been  found  in  many  instances  to  be  virulently  infective  to  animals. 
It  is  apparent,  from  a  review  of  the  foregoing,  that  the  evidence  relating 
to  cutaneous  infection  is  more  or  less  conflicting.  It  is  safe  to  assume, 
however,  that  inoculation  with  tuberculous  material  is  much  more 
frequent  than  commonly  suppo.sed  and  likely  to  be  attended  by  serious 
consequences.  It  is  probable  that  the  danger  of  infection  through  the 
skin  is  greater  from  tubercle  bacilli  of  human  origin  than  from  the 
bovine  variety.  The  role  of  the  skin  as  an  avenue  of  tuberculous 
infection  should  not  be  dismissed  as  of  trifling  significance,  although 
this  was  formerly  believed  to  be  the  case. 

The  relation  of  tuberculous  lesions  of  the  skin  to  the  existence  of 
infective  processes  in  other  parts  of  the  body  is  of  considerable  impor- 
tance. Among  my  own  patients  I  have  been  unable  to  procure  suflScient 
data  as  to  the  comparative  frequency  of  cutaneous  tuberculosis  aynong 
consumptives  to  hazard  even  an  approximate  opinion  upon  this  subject. 
My  experience  has  been  confined  to  the  observation  of  a  class  of  patients 
outside  of  free  dispensaries  and  charitable  institutions  and,  therefore, 
would  hardly  reflect  a  correct  estimate  of  the  actual  proportion  of  such 
cases.  It  is  well  known  that  the  cutaneous  lesions  are  more  common 
among  the  ignorant  and  uncleanly,  on  account  of  the  much  greater 
opportunity  for  infection.  Among  my  private  cases  of  pulmonary 
tuberculosis,  however,  numbering  in  excess  of  two  thousand,  I  recall 
but  two  instances  of  lupus,  one  appearing  upon  the  forehead  and  one 
over  the  sternum,  and  a  single  ulcerative  tuberculous  process  upon  the 
female  genitals.  Upon  the  other  hand,  the  evidence  is  conclusive 
regarding  the  frequency  of  pulmonary  involvement  among  the  victims 
of  cutaneous  tuberculosis.  Bender  made  inquiry  in  159  cases  of  lupus, 
and  found  existing  tuberculosis  elsewhere  in  77  cases,  and  a  history  of 
previous  involvement  in  22  others.  Fox,  in  a  class  of  96  hospital  cases 
of  his  own,  reported  .33  instances  of  glandular  involvement.  Among 
144  cases  cited  by  Bloch,  114  exhibited  other  evidence  of  tuberculous 


520  COMPLICATIONS 

infection.  Sachs  reported  115  patients,  among  whom  only  15  failed  to 
present  a  history  of  hereditary  infection  or  of  active  tuberculous  disease 
(Stel wagon).  Of  66  cases  of  lupus  reported  by  the  same  observer,  all 
of  whom  exhibited  evidence  of  tuberculous  infection  in  other  regions, 
36  were  definitely  tuberculous  before  the  development  of  lupus.  Besnier 
records  8  cases  of  pulmonary  tuberculosis  among  a  total  of  38  suffering 
from  lupus,  and  Leloir,  98  out  of  a  total  of  312  (Cornet).  A  lessened 
resistance  of  the  tissues  to  bacillary  invasion,  and  added  means  of  infec- 
tion either  from  without,  as  a  result  of  accidental  inoculation,  or  from 
contiguity  of  diseased  structures,  constitute  ample  explanation  of  the 
greater  prevalence  of  cutaneous  lesions  among  individuals  afflicted  with 
other  forms  of  tuberculosis. 

Variations  in  the  clinical  manifestations  and  in  the  character  of 
the  pathologic  change  in  the  several  forms  of  skin  tuberculosis  are 
believed  to  be  due  largely  to  essential  differences  in  the  nature  of  the 
infective  agents.  Besnier,  Leloir,  and  Tavernier  regard  a  secondary 
infection  as  the  chief  etiologic  factor  in  the  development  of  tuberculous 
ulcers,  and  the  inoculation  of  tubercle  bacilli  alone  as  the  determining 
feature  in  the  production  of  the  verrucous  forms.  According  to  Stel- 
wagon,  they  differentiate,  in  the  various  phases  of  lupus,  between  a 
neoplastic  and  a  suppurative  process,  the  former  being  ascribed  to  the 
irritative  action  of  the  tubercle  bacillus,  and  the  latter  to  the  presence 
of  the  staphylococcus  aureus.  Wright  is  of  the  opinion  that  all  cases 
of  suppurative  lupus  are  associated  with  a  staphylococcic  infection, 
and  that  especially  aggravated  cases  of  lupus  exhibit  invariably  a 
streptococcic  infection. 

The  tuberculous  character  of  the  cutaneous  lesions  has  been  demon- 
strated by  the  presence  of  the  bacilli,  their  growth  in  pure  culture, 
the  results  of  animal  experimentation,  and  the  tuberculin  test.  Such 
an  array  of  testimony  regarding  the  nature  of  the  condition  appears  for 
clinical  purposes  to  be  quite  sufficient,  despite  the  dictum  of  Virchow 
that  the  presence  of  a  true  pathologic  tubercle  is  the  sole  determining 
factor  in  genuine  tuberculosis.  He  discriminated  between  a  bacter- 
iologic  and  a  pathologic  tubercle,  the  latter  being  a  cellular  organization, 
developed  from  the  tissues  of  the  host,  though  stimulated  originally  by  the 
irritative  effect  of  tubercle  bacilli.  He  emphasized  the  essential  forma- 
tive or  productive  element  of  the  cells,  which  is  not  inherent  to  the 
bacilli  alone.  Judged  solely  by  this  token,  it  is  difficult  to  reconcile  the 
structure  of  certain  forms  of  bacillary  skin  invasion,  viz.,  the  verrucous 
types,  lupus  vulgaris,  and  the  ulcerative  lesions,  with  true  tuberculosis. 
The  anatomic  structure  of  scrofuloderma,  however,  is  closely  analogous 
to  that  of  tuberculosis  of  other  organs,  the  subcutaneous  tissue  being 
the  seat  of  small  round-cell  proliferation,  with  epithelioid  cells  and  occa- 
sionally giant-cells.  .\s  degeneration  progresses  ulceration  finally  takes 
place  through  the  superficial  layers  of  epidermis.  On  account  of  the 
divergence  in  the  pathologic  and  histologic  structure  of  lupus  from  tuber- 
culous processes  elsewhere,  it  has  been  suggested  that  the  lesions  were 
produced  by  two  different  types  of  tubercle  bacilli,  though  possessing 
the  same  morphologic  and  biologic  characteristics,  but  this  view  is  not 
entertained  to  any  extent  at  present.  Reference  has  been  made  to  the 
hypothesis  advanced  by  Smith  and  others  that  the  various  recognized 
differences  between  the  several  types  of  tubercle  bacilli  may  be  attribut- 
able in  part  to  a  change  in  the  host,  and  that  the  same  organism  ulti- 


PLATE     13. 


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m 


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ife-? 


all! 
I.  ^  ii 

E -I  I  g 


t^' 


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lis 


3-0.2  <u-B 


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E  2 


■a  5 


TUBERCULOSIS    OF    THE    SKIN  521 

mately  undergoes  certain  modifications  through  its  selective  adaptation 
and  environment.  The  histologic  features  of  lupus,  though  by  no  means 
identical  with  those  of  true  pathologic  tubercle,  yet  in  connection  with 
the  presence  of  the  bacilli  are  sufficiently  similar  to  justify  its  inclusion 
in  the  same  general  category.  As  compared  with  the  classic  tubercle  of 
Virchow,  there  are  a  less  number  of  epithelioid  cells  and  a  proportion- 
ate increase  in  the  number  of  giant-cells.  According  to  Bowen,  there 
are  an  increased  vascularity  and  a  greater  proliferation  of  connective 
tissue.  The  giant-cell  is  also  found  in  gummatous  deposits  and  other 
granulomata.  Degenerative  changes  take  place,  but  are  of  insidious 
onset  and  slow  development,  owing  to  the  comparatively  small  number 
of  bacilli.  For  the  same  reason  connective-tissue  hyperplasia  is  per- 
mitted to  a  greater  extent  than  in  true  pathologic  tubercle,  a  cicatrix 
often  being  formed,  sometimes  of  hypertrophic  \':iriety.  In  the  ver- 
rucous form  the  chief  distinctive  characteristic  of  the  neoplasm,  as 
opposed  to  the  papillary  variety  of  lupus,  is  the  location  of  the  growth 
in  the  upper  layers,  rather  than  in  the  middle  and  lower  portions  of  the 
corium. 

The  clinical  appearance,  diagnosis,  prognosis,  and  treatment  of  the 
various  forms  of  cutaneous  tuberculosis  involve  considerations  of  so 
purely  technical  nature  as  to  preclude  the  propriety  of  their  introduc- 
tion in  a  work  devoted  to  pulmonary  tuberculosis.  As  a  possible  com- 
plication of  this  condition,  however,  a  brief  resume  of  the  more  impor- 
tant features  is  perhaps  permissible. 

Varieties. — The  ordinary  verrucous  variety  has  been  described  in 
the  preceding  pages  as  possessing  a  tendency  to  extend  superficially, 
often  invading  several  inches  upon  the  dorsal  aspect  of  the  hand. 
The  spread  of  the  infection  may  be  such  as  to  involve  the  fingers  and 
entire  digital  folds,  sometimes  the  wrists,  but  rarely  the  palms.  The 
peripheral  extension  may  produce  a  coalescence  of  several  discrete 
patches,  with  a  resulting  irregular  outline.  The  infected  region  presents 
the  appearance  of  wart-like  projections  arising  from  an  infiltrated 
reddened  or  purplish  area.  The  nodules  may  be  fairly  discrete,  or 
aggregated  in  close  apposition  to  each  other.  Upon  the  summit  of  the 
papillary  vegetation  very  small  pustules  are  sometimes  found.  The 
affection  is  of  slow  growth,  and  exhibits  a  decidedly  sluggish  course, 
there  being  almost  never  a  tendency  to  ulcerate.  It  may  last  indefi- 
nitely, or  disappear  without  obvious  reason. 

The  necrogenic  wart  is  a  single,  isolated  papillary  formation,  without 
tendency  toward  ulceration  or  extensive  peripheral  spread.  It  may 
occur  upon  any  portion  of  the  dorsum  of  the  hand,  though  observed 
more  commonly  in  the  region  of  a  joint.  It  increases  in  size  very 
slowly,  sometimes  attaining  a  growth  of  over  one  inch  in  diameter, 
which  is,  in  fact,  considerably  in  excess  of  its  ordinary  proportions. 
The  appearance  is  that  of  an  irregular,  hard,  warty  excrescence,  which 
is  somewhat  flattened  and  reddened.  In  some  cases  a  slight  pus-for- 
mation is  present,  with  associated  small  pustular  crusts.  The  course  is 
slow,  and  the  duration  of  the  lesion  indefinite,  though  spontaneous 
healing  may  occasionally  take  place. 

The  ulcerative,  form,  of  cutaneous  tuberculosis  relates  to  the  initial 
presence  of  tiny  miliary  tubercles  and  their  subsequent  caseation, 
softening,  and  ulceration.  As  previously  stated,  this  variety  is  found 
in  proximity  to  the  mucous  orifices,  especially  the  mouth,  nose,  anus, 


522  COMPLICATIONS 

and  external  genitals.  It  is  observed  almost  exclusively  among  subjects 
of  pulmonary  tuberculosis,  and  is  directly  occasioned  by  the  infected 
mucous  discharge,  together  with  an  added  susceptibility  of  tissues. 
Lesions  within  the  mucous  channels  are  usually  demonstrable.  The 
ulcers,  as  a  ride,  are  superficial  and  irregular,  with  soft  edges.  The 
floor  is  rarely  smooth,  but  presents  slight  granulating  projections  of  an 
indolent  appearance,  with  scanty  secretion  and  dirty  reddish  color. 

The  disseminated  form  of  skin  tubercidosis  is  observed  too  rarely 
to  warrant  more  than  passing  allusion.  This  condition  is  often  acute  in 
type,  and  consists  of  the  eruption  of  diffused  lesions  of  a  multiform 
nature.  The  process  is  scattered  upon  almost  any  portion  of  the  body, 
and  may  resemble  a  variety  of  cutaneous  affections.  It  occurs,  however, 
in  conjunction  with  a  recognized  tuberculous  infection  in  other  regions. 

The  scrofulous  ti/pe  of  ulceration  occurs  particularly  in  connection 
with  contiguous  caseating  and  suppurating  lymphatic  glands.  The 
initial  involvement  of  the  skin  is  manifested  bj'  the  dull  red  and  glistening 
appearance,  which  is  observed  over  the  site  of  the  enlarged  gland  soon 
after  the  process  of  softening  has  been  established.  The  cUstended 
skin  soon  undergoes  one  or  more  minute  points  of  degeneration,  which 
become  the  openings  of  small  sinuses  connecting  with  the  infected 
glands.  These  ulcerative  orifices  assume  larger  proportions  and  the 
adjacent  skin  is  broken  down  throughout  an  increasing  area.  An 
ulcer  is  formed  which  maj^  attain  the  size  of  a  plum.  The  most  fre- 
quent site  is  over  the  cervical  glands,  but  similar  lesions  may  appear  in 
portions  of  the  body  remote  from  and  irrespective  of  lymphatic  enlarge- 
ment. The  ulcerative  process  displays  but  slight  tendency  to  progress 
deeply,  but  may  exhibit  a  gradual  lateral  spread.  There  is  but  little 
infiltration  of  the  outlj-ing  tissues.  The  edges  are  thin,  dully  reddened, 
and  sometimes  slightly  undermined,  the  contour  irregular,  and  the  floor 
superficial  without  marked  vegetating  granulations.  The  course  is  slow 
and  disappointing.  This  variety  of  cutaneous  tuberculosis  is  occasion- 
ally observed  in  children  in  conjunction  with  other  tuberculous  proc- 
esses.    (See  plate  13.) 

Lupus  mdgaris,  as  previously  stated,  consists  of  a  definite  structural 
formation  in  the  deeper  portion  of  the  corium,  closely  analogous  to  that 
of  true  pathologic  tubercle.  In  addition  to  the  tubercle  formation, 
essential  characteristics  are  the  retrogressive  changes,  ulceration,  heal- 
ing with  cicatrization,  and  the  insidious  development  of  new  le.sions  by 
peripheral  extension.  The  early  manifestations  are  the  appearance  of 
macules  or  papules  of  a  dull  red  color,  followed  by  the  formation  of  a 
patch  of  agglomerated  nodular  tubercles.  Degeneration  of  the  infiltrated 
portions  takes  place,  and  in  turn  is  succeeded  by  a  shallow  indolent 
ulceration.  A  slight  secretion  of  a  purulent  nature  is  usually  present. 
Crusts  appear  from  time  to  time  and  remain  for  a  variable  period  unless 
subject  to  active  treatment.  Healing  often  takes  place  with  the  for- 
mation of  scar  tissue.  New  areas  become  affected  either  along  the  bor- 
ders of  the  infiltrated  region,  or  even  at  the  site  of  the  cicatrix  resulting 
from  the  initial  lesion.  The  patient  with  lujius  of  the  forehead  presented 
the  history  of  a  rapid  appearance  of  new  foci  in  the  same  region,  despite 
a  complete  previous  healing  of  the  process.  Under  :r-ray  treatment 
cicatrization  was  again  induced.  The  location  of  the  lupus  in  this  case, 
and  the  appearance  of  the  lesion  before  the  x-ray  treatment  was  insti- 
tuted, is  shown  in  plate  14,  figure  1.    The  present  condition  is  shown  in 


Fig.  1. — Lupus  vulgaris  of  the  forehead  of  several  years'  duration.     Note  irregular 
distribution,  nodular  appearance,  the  shallow  ulceration,  and  crusts. 

Fig.  2. — Area  of  cicatrization  in  case  of  lupus  vulgaris  of  the  forehead  after  healing 
has  taken  place.     Same  patient  as  preceding.     Note  faint  pinkish  discoloration. 


TUBERCULOSIS   OF    THE    SKIN  OZd 

plate  14,  figure  2,  from  a  recent  painting  after  cicatrization  had  become 
complete.  In  plate  15  is  shown  the  appearance  of  another  lupus,  involv- 
ing the  anterior  surface  of  the  chest,  of  many  years'  duration.  The 
nodular  character  of  the  lesions  in  this  case  was  especially  marked,  as 
was  the  tendency  to  bleed  upon  manipulation. 

The  face  is  the  usual  site  of  the  disease,  especially  the  region  of  the 
nose,  but  it  may  occur  in  any  part  of  the  body.  \'ariations  from  the  com- 
mon type  of  the  lesion  are  exemplified  in  the  hypertrophic,  sclerotic, 
papillomatous,  serpiginous,  and  edematous  forms,  the  natui'e  of  which  is 
characterized  by  their  respective  names.  Lupus  is  associated,  as  a  rule, 
with  no  evidence  of  constitutional  disturbance.  The  course  is  protracted 
and  invariably  disappointing,  the  periods  of  improvement  alternating 
with  those  of  comparatively  rapid  progression.  The  condition  may  be 
stationary  or  quiescent  for  prolonged  periods. 

Diagnosis. — The  more  important  difficulties  in  the  way  of  diagnosis 
of  the  various  forms  of  cutaneous  tuberculosis  attach  to  the  differentia- 
tion of  lupus  vulgaris  from  epithelioma  and  syphilis.  Epithelioma  is 
usually  a  cUsease  of  later  years,  and  is  not  associated  with  a  history  of 
tuberculosis  elsewhere.  The  ulceration  arises  from  a  sharply  localized 
spot,  the  previous  condition  being  that  of  an  apparently  benign  mole, 
wart,  or  incrustation.  The  destructive  change,  as  a  rule,  is  less  super- 
ficial, is  more  rapid,  attended  with  greater  loss  of  substance,  and  rarely 
manifests  any  tendency  toward  spontaneous  healing. 

Syphilis  is  more  difficult  of  accurate  differentiation,  especially  if  the 
lesion  appears  upon  the  face.  It  is  much  more  frociuent  than  lupus,  and 
hence  more  likely,  in  case  of  reasonable  (inuht,  tci  he  the  cause  of  the 
cutaneous  affection.  The  history  of  the  ]);itieiit  is  of  considerable 
value,  but  not  of  paramount  importance.  An  emphatic  denial  of  early 
syphilis  is  not  entitled  to  absolute  credence.  A  negative  result  in  the 
effort  to  elicit  an  admission  of  a  previous  specific  manifestation  is  of 
more  consequence.  The  existence  or  history  of  pulmonarj'  tuberculosis 
is  inconclusive,  inasmuch  as  syphilis,  like  lupus,  may  occasionally  occur 
in  conjunction  wdth  tuberculous  processes  in  other  parts  of  the  body. 
As  with  epithelioma,  syphilis  of  the  face,  except  initial  lesions,  is  more 
likely  to  appear  in  later  life  than  lupus.  The  course  of  the  disease 
is  considerably  more  rapid  in  .syphilis  than  in  lupus,  the  ulcerations  are 
usually  deeper,  and  attended  by  a  more  profuse  secretion.  Stelwagon 
calls  attention  to  the  darker,  more  copjjei'v-red  color  of  the  syphilitic 
lesions  in  contrast  to  the  brownish  yellow  or  red  of  lupus.  The  con- 
figuration of  the  cutaneous  affection  is  also  more  irregular  and  eccentric 
in  syphilis.  On  account  of  the  paucity  of  tul)ercle  bacilli  in  the  infected 
area,  the  results  of  microscopic  examination  of  the  secretion  and  of 
animal  inoculation  in  lupus  are  more  or  less  untrustworthy.  Tuberculin 
injections  and  the  ophthalmotuberculin  test  are  of  undoubtecl  value, 
and  should  be  resorted  to  in  obscure  cases,  especially  after  failure  to 
secure  improvement  from  antisyphilitic  medication.  It  is  known, 
however,  that  a  positive  reaction  from  tuberculin  injections  may 
occasionally  take  place  in  cases  of  pure  syphilitic  infection. 

The  prognosis  of  lupus  is  at  best  uncertain.  Much  ilo|if>ii(ls,  of 
course,  upon  the  general  condition  and  the  extent  nf  niliiiculous 
processes  in  other  parts  of  the  body.  The  personal  equal  imi  is  also  a 
most  important  factor,  as  most  patients,  on  account  of  the  slow  and 
unsatisfactory  progress  and  the   frequent  renewed  exacerbations  fol- 


524  COMPLICATIONS 

lowing  an  apparent  recovery,  become  exceedingly  difficult  to  manage. 
Thus  the  individuality  of  the  patient  and  of  the  physician  assumes  a 
degree  of  inportance  in  the  character  of  ultimate  results.  In  general, 
it  may  be  stated  that  if  the  involved  area  is  not  too  extensive  before 
active  medical  interference  is  instituted,  fairly  satisfactory  progress 
toward  securing  cicatrization  may  be  maintained.  The  process  of 
recovery  is,  however,  tedious  to  a  degree,  and  demands  the  exercise  of 
great  patience,  perseverance,  and  intelligence,  qualities  not  always 
attributable  to  this  class  of  patients.  The  disease  is  commonly  regarded 
as  less  virulent  in  this  country  than  abroad. 

Treatment. — The  rational  management  of  lupus,  as  of  other  varieties 
of  cutaneous  tuberculosis,  involves  the  adoption  of  both  constitutional 
and  local  measures.  The  general  health  must  be  conserved  and -encour- 
aged in  all  instances.  Precisely  as  in  other  forms  of  tuberculosis,  it  is 
the  individual  as  well  as  the  local  condition  that  appeals  to  the  medical 
attendant  for  advisory  and  supervisory  attention.  The  treatment  of 
the  general  condition  is  perhaps  no  less  important  than  in  pulmonary 
tuberculosis,  and  includes  the  consideration  of  such  therapeutic  agents 
as  climatic  change,  hygienic  surroundings,  and  appropriate  medication. 
The  general  management  should  be  based  upon  the  same  principles  of 
nutrition,  sunshine,  and  outdoor  life  as  have  been  described  in  connection 
with  tuberculosis  of  the  glands,  bones,  joints,  and  the  genito-urinary 
system.  Medicinal  therapeutics  comprise  the  administration  of  the 
various  tonic  and  constructive  remedies,  aids  to  digestion  and  prepara- 
tions directed  to  the  relief  of  special  disturbances.  In  addition,  definite 
benefit  may  sometimes  be  expected  from  the  employment  of  the  tubercle 
bacilli  emulsion  in  carefully  adjusted  doses.  In  ulcerative  forms  due 
to  the  presence  of  staphylococcic  infection  a  homologous  vaccine  made 
from  a  pure  staphylococcic  culture  should  offer  satisfying  results  in 
occasional  instances.  In  former  years,  under  the  use  of  the  old  tuber- 
culin of  Koch,  rapid  healing  was  induced  in  many  cases,  but  the  relapses 
were  frequent  and  sudden,  and  the  method  was  gradually  abandoned. 

The  local  management  embraces  the  use  of  topical  applications  of 
a  soothing  or  destructive  nature,  the  x-ray  or  the  concentrated  light  of 
Finsen,  and  operative  measures.  The  number  of  local  applications 
recommended  by  various  dermatologists  under  the  several  conditions 
presented  is  almost  infinite.  Their  enumeration,  as  well  as  the  descrip- 
tion of  the  technic  of  the  operative  methods,  belong  strictly  within  the 
domain  of  dermatology  or  general  surgery.  The  procedure  usually 
adopted  is  that  of  curetment  and  scarification.  Excellent  results  have 
been  reported  to  attend  the  use  of  the  Finsen  light.  The  x-rays  are  of 
undoubted  benefit  in  many  cases. 


CHAPTER  LXXVII 
TUBERCULOSIS  OF  THE  LARYNX 

This  condition  is  undoubtedly  the  most  frequent  complication  of 
pulmonary  tuberculosis.  Statistical  observations  as  to  the  proportion 
of  cases  of  laryngeal  involvement  among  consumptives  are  more  or 


PLATE     i;. 


\. 


Lupus  vulgaris  involving  the  anterior  surface  of  the  chest,  of  many  yeai's'  duration, 
in  a  woman  sixty-five  yeai-s  of  age.  Note  especially  the  marked  protuberance  over  the 
center  of  the  sternum,  the  characteristic  smaller  nodules,  the  crusts,  blood-clots,  and 
marginal  healing. 


TUBERCULOSIS    OF    THE    LARYNX  525 

less  divergent.  Bosworth,  from  an  analysis  of  a  large  number  of  collated 
cases,  concludes  that  tuberculosis  of  the  larynx  exists  in  about  one-third 
of  all  cases  of  pulmonary  phthisis.  He  believes,  however,  that  from 
a  clinical  standpoint,  the  number  exhibiting  subjective  symptoms  do 
not  exceed  13  per  cent.,  as  previously  stated  by  Willigk.  According 
to  Thompson,  the  pathologic  statistics  from  the  Brompton  Consumption 
Hospital  demonstrated  an  actual  tuberculous  involvement  of  the  larynx 
in  50  per  cent,  of  all  cases  of  consumption  coming  to  autopsy.  Cornet 
has  referred  to  the  statistics  of  several  observers,  who  reported  as  follows: 
Kruse,  16.6  per  cent,  out  of  742  cases  of  consumption;  Gaul,  25.7  per 
cent,  out  of  424  cases;  Eichhorst,  28.1  per  cent,  out  of  462  autopsies; 
Heinze,  30.6  per  cent,  out  of  1236  autopsies;  de  Lamallerie,  44.2  per 
cent,  out  of  502  cases. 

In  connection  with  these  analyses  it  is  important  to  call  attention  to 
the  essentially  different  conditions  obtaining  in  the  computation  of 
statistics  based  upon  the  autopsy  findings,  and  those  founded  purely 
upon  clinical  observation.  In  the  former  the  patients  had  succumbed 
to  an  exhausting  disease  of  a  tuberculous  nature,  abundant  opportunity 
for  secondary  infection  having  been  provided  through  overwhelming 
exposure  and  absence  of  tissue  resistance.  In  the  other  cases  the 
clinical  evidence  relates  to  the  exhibition  of  subjective  and  objective 
signs  among  individuals  in  all  stages  of  pulmonary  disease,  in  many  of 
whom  the  process  is  undergoing  arrest.  Obviously,  there  is  afforded 
but  little  opportunity  for  comparison.  It  is  manifestly  improper  to 
state  that  because  approximately  one-third  of  all  tuberculous  subjects 
at  autopsy  exhibit  laryngeal  disease,  a  similar  ratio  must  exist  among 
pulmonary  invalids  as  a  class.  One  author  has  assumed  that  inasmuch 
as  50  per  cent,  of  the  autopsies  upon  pulmonary  invalids  at  the  Bromp- 
ton Hospital  in  London  showed  pathologic  changes  in  the  larynx, 
and  as  70,000  people  die  annually  in  England  from  con.sumption,  it 
must  follow  that  35,000  sufferers  from  laryngeal  tuberculosis  succumb 
each  year  in  the  United  Kingdom,  and  not  less  than  75,000,  "upon  the 
statistics  of  averages,"  who  are  at  present  afflicted  with  the  disease. 
Others  have  gone  so  far  as  to  indulge  in  the  sophistry  that  if  laryngeal 
tuberculosis  affects  nearly  one-half  of  all  consumptives,  and  if  pulmonary 
tuberculosis  comprises  one-seventh  of  all  deaths,  then  about  one- 
fourteenth  of  the  population  must  suffer  from  tuberculosis  of  the  larynx. 
As  a  matter  of  fact,  the  clinical  manifestations  of  laryngeal  tuberculosis 
are  not  as  frequent  among  pulmonary  invalids  as  the  pathologic  findings 
at  autopsy  would  iiidimto.  Further,  it  should  be  borne  in  mind  that 
the  laryngeal  Inrnlniiii  nl  iii:i\-  in  some  cases  be  quite  devoid  of  chnical 
significance  and  it'innin  ;[  failure  entireli/  suboi-dinalc  to  the  pulmonary 
affection.  In  a  considerable  number  of  cases,  however,  the  laryngeal 
disturbance  assumes  a  prominence  sufficient  to  overshadow  all  other 
considerations.  Among  pulmonary  invalids,  on  account  of  the  coexis- 
tence of  a  considerable  variety  of  non-tuberculous  laryngeal  lesions, 
it  is  easy  to  understand  how  there  may  arise  radically  differing  statisti- 
cal observations.  Schrotter  reported  laryngeal  tuberculosis  in  6  and 
8  per  cent,  of  his  cases  of  pulmonary  consumption,  while  McKenzie 
recognized  its  existence  in  33  per  cent,  of  such  cases.  Chronic  catarrh 
of  the  larynx,  though  of  frequent  occurrence  among  phthisical  patients, 
and  predisposing  more  or  less  to  the  development  of  a  local  tuberculous 
infection,  is  unworthy  of  inclusion  among  cases  of  laryngeal  tuberculosis. 


526  COMPLICATIONS 

Etiology. — Tuberculosis  of  the  larynx  may  be  primary  or  secondary, 
but,  in  the  great  majority  of  instances,  its  secondary  character  is  estab- 
lished. Many  clinicians  have  been  led  to  question  the  existence  of 
a  primary  infection,  but  the  evidence  that  such  occasionally  takes  place 
appears  incontrovertible. 

There  came  under  my  observation,  in  the  early  part  of  1907,  a 
young  man  who  arrived  in  Colorado  three  months  after  the  recognition 
of  a  tuberculous  infection.  There  was  very  pronounced  hoarseness 
and  slight  cough  with  expectoration.  A  loss  of  twenty  pounds  in 
weight  was  exhibited,  but  there  had  been  no  temperature  elevation. 
Upon  examination  there  was  a  complete  absence  of  the  physical  evi- 
dences of  pulmonary  infection,  but  the  sputum  was  found  to  contain 
innumerable  tubercle  bacilli  as  well  as  the  microorganisms  of  mixed 
infection.  Examination  showed  the  interior  of  the  larynx  to  be  pur- 
plish red  with  irregular,  slightly  nodular  infiltration  of  both  vocal  bands. 
The  subglottic  infiltration  was  covered  with  hemorrhagic  spots,  and  the 
arytenoids  were  swollen  and  red.  The  infiltration  upon  the  left  side 
was  more  marked  than  upon  the  right.  It  is  quite  unwarrantable  to 
assume  the  existence  of  a  primary  infection  simply  upon  the  basis 
of  a  negative  physical  examination  of  the  chest.  The  possibility  of 
failure  to  detect  the  presence  of  a  small  tuberculous  focus  in  the  lungs 
should  be  fully  recognized.  In  connection,  however,  with  the  absence 
of  other  clinical  evidences  of  pulmonary  disease,  and  in  view  of  the 
positive  conclusions  derived  by  several  pathologists  with  reference  to 
the  possibility  of  primary  laryngeal  tuberculosis,  it  is  reasonable,  in 
this  case,  to  question  a  pulmonary  infection  prior  to  the  detection  of 
physical  signs  or  the  development  of  laryngeal  lesions. 

In  general  authentic  evidence  of  primary  laryngeal  tuberculosis  can 
be  obtained  only  through  recourse  to  the  postmortem  findings.  Massucci 
reported  several  cases  of  primary  laryngeal  tuberculosis  without  the 
discovery  of  pulmonary  lesions  at  autopsy.  Orth  has  recorded  a  single 
instance  of  similar  character.  Demme  has  described  a  case  of  larynseal 
tuberculosis  in  a  child  four  and  one-half  years  old.  who  died  of  tuber- 
culous meningitis,  and  in  whom  the  pulmonary  tissues  were  unaffected. 
Numerous  cases  have  been  recorded  by  observers  illustrating  the 
greatly  delayed  pulmonary  involvement  following  an  apparently 
primary  laryngeal  infection.  It  is  not  uncommon  to  detect  eventually 
the  characteristic  signs  of  pulmonary  infection  among  individuals  in 
whom  the  evidences  of  tuberculous  involvement  were  at  first  confined 
to  the  larynx.  The  clinical  recognition,  however,  of  tuberculous  proc- 
esses in  the  lung  after  the  lapse  of  many  months  subsequent  to  well- 
defined  laryngeal  tuberculosis,  does  not  in  itself  refute  the  assumption 
of  a  primary  infection  of  the  larynx. 

It  is  true  that,  in  general,  tuiserculosis  of  the  larynx  either  accom- 
panies or  occurs  as  a  later  complication  of  pulmonary  consumption. 
The  infection  in  .some  ca.ses  is  probably  produced  as  a  result  of  the 
passage  and  retention  of  bacilli-laden  sputum.  The  peculiarities  of 
anatomic  construction  of  the  interior  of  the  larynx  are  such  as  to  afford 
especial  opportunity  for  the  lodgment  of  tiny  masses  of  sputum.  The 
complexity  of  structure  of  the  many  parts  of  the  larynx,  the  variety  of 
affections,  the  almo.st  unceasing  movements  in  respiration,  vocalization, 
coughing,  and  deglutition,  the  irregular  disposition  of  the  mucous 
membrane  in  intralaryngeal    folds,    and    its   intimate   attachment  to 


TUBERCULOSIS    OF    THE    LARYNX  527 

underlying  tissues,  all  combine  to  favor  a  secondary  infection  in  a 
region  traversed  frequently  by  the  bacilli.  Not  only  are  unusual 
facilities  offered  for  the  hospitable  reception  of  bacilli,  but  the  local 
structures  are  subject  to  constant  irritation  by  reflex  excitability  and 
trauma.  Cornet  has  called  attention  to  the  fact  that  the  stagnating 
sputum  permitted  to  remain  in  various  portions  of  the  larynx  is  usually 
retained  in  close  proximity  to  a  joint,  and  in  such  position  that  with  the 
normal  movements  of  the  larynx  a  massage-like  motion  is  imparted. 

Infection  also  takes  place  occasionallj'  through  the  circulation. 
This  method  of  bacillary  transmission  to  the  larynx  occurs  largely  as 
a  local  instance  of  a  general  miliary  invasion.  The  process  is  usually 
more  or  less  acute  in  type,  and  is  attended  by  other  manifestations 
suggestive  of  the  systemic  involvement.  As  to  whether  or  not  local 
infection  may  result  through  the  medium  of  the  vascular  channels 
other  than  in  general  miliary  tuberculosis,  opinions  differ  widely.  Some 
assert  that  the  location  of  the  tuberculous  process  in  the  subepithelial 
tissue  and  the  scant  number  of  bacilli  toward  the  epithelial  surface  are 
a  priori  evidence  that  the  invasion  took  place  from  within.  This  basis 
of  reasoning,  however,  is  unsupported  by  the  accumulated  evidence  of 
many  observers,  who  have  demonstrated  the  passage  of  bacilli  through 
an  intact  mucous  membrane  in  various  parts  of  the  body.  Further, 
irrespective  of  the  larynx,  the  infiltrative  process  is  known  to  be  more 
active  in  the  deeper  tissues  of  the  various  organs.  Therefore,  the 
universal  predilection  of  the  bacilli  for  the  subepithelial  portion,  even 
if  true,  would  afford  no  argument  against  direct  infection  through  the 
epithelial  surface  of  the  mucous  membrane.  Tubercle  bacilli  have  been 
found,  moreover,  in  large  numbers,  upon  the  surface  of  larj^ngeal  ulcers. 
In  the  case  of  apparent  primary  tuberculosis  of  the  larynx  previously 
cited,  without  pulmonary  signs,  the  sputum  expelled  in  the  act  of 
clearing  the  throat  was  peppered  with  bacilli,  although  the  process 
in  the  larynx  remained  essentially  superficial. 

If  the  fact  of  hematogenous  infection  be  denied,  save  in  eases  of 
general  miliary  tuberculosis,  it  is  difficult  to  explain  satisfactorily  the 
development  of  laryngeal  involvement  prior  to  pulmonary  infection, 
save  upon  the  assumption  of  extension  from  a  concealed  focus  through 
the  lymphatics.  Such  method  of  development  involves  necessarily 
the  previous  existence  of  some  neighboring  tuberculous  focus,  which, 
if  incapable  of  demonstration  at  autopsy,  suggests  the  possibility  of 
inhalation  infection  in  .some  cases  of  primary  laryngeal  involvement. 
The  testimony  thus  far  adduced  as  to  this  possibility  is  by  no  means 
convincing.  The  demonstration  of  tulinrlc  bacilli,  in  the  nostrils 
of  nurses  and  attendants  in  sanatoria,  as  well  as  in  the  tonsillar  crypts 
and  adenoid  growths  of  children,  woukl  affdnl  prima  facie  evidence  of 
their  entrance  into  the  larynx  of  mouth-breathers.  In  cases  of  primary 
tuberculosis  of  the  larynx  a  consideration  in  favor  of  an  inhalation 
infection  is  the  fact,  to  which  allusion  has  been  made,  that  in  laryngeal 
invasion  occurring  as  a  local  manifestation  of  general  miliary  tubercu- 
losis, the  process  is  acute,  displaying  a  somewhat  uniform,  bilateral 
involvement,  with  the  tissues  more  or  less  edematous.  If  this  be  true 
in  the  event  of  hematogenous  infection  attending  a  general  systemic 
invasion,  it  may  be  questioned  why  it  should  not  also  be  the  case  if 
infection  occurs  through  the  medium  of  the  vascular  channels  without  a 
general  miliary  tuberculosis.     It  so  happens,   however,  that  cases  of 


528  COMPLICATIONS 

primary  laryngeal  tuberculosis  do  not  exhibit  the  characteristic  appear- 
ance, nor  manifest  the  typical  course,  obtaining  in  general  miliary 
infection.  In  the  former  the  lesions  are  usually  unilateral  at  first,  of 
slow  development,  and  chronic  course.  The  assumption  appears 
tenable,  therefore,  that  in  cases  of  primary  involvement  the  source  of 
infection  is  not  invariably  attributable  to  the  circulation. 

An  attempt  has  been  made  by  some  observers  to  demonstrate,  in 
cases  of  secondary  laryngeal  involvement,  an  especial  predilection  to 
tuberculous  infection  iipon  the  sit'e  corresponding  to  the  pulmonary 
disease.  This  has  failed  of  sulistantiation  in  almost  all  instances, 
though  Schrotter  claims,  out  of  114  autopsies,  to  have  found  this  rela- 
tion in  74.  It  is  difficult  to  explain  such  phenomena  upon  the  basis  of 
any  physiologic  data.  It  would  seem  that  a  rational  explanation  of  a 
unilateral  disturbance  of  function  within  the  larynx  is  offered  by 
compression  of  the  recurrent  laryngeal  nerve  as  a  result  of  pleural 
thickening  or  enlarged  mediastinal  glands.  A  noteworthy  instance 
of  the  latter  is  found  in  the  ease  reported  upon  page  427.  It  is 
impossible,  however,  to  reconcile  in  this  manner  a  corresponding 
unilateral  tubercle  deposit  in  the  larynx.  I  have  had  occasion  many 
times  to  observe  an  active  laiyngeal  tuberculosis  confined  to  the  side 
opposite  the  pulmonary  infection.  A  conspicuous  example  has  come 
under  observation  and  is  illustrated  by  the  drawing,  Fig.  129,  which 
shows  the  initial  tubercle  deposit  to  have  involved  the  left  side  of 
the  epiglottis.  In  this  case  the  early  sj-mptoms  referable  to  a  tuber- 
culous process  developed  with  hoarseness  in  1887.  For  several  years 
the  patient  remained  under  the  continuous  observation  of  expert 
laryngologists  in  this  country,  as  well  as  abroad.  On  account  of  the 
badly  ulcerated  condition  of  the  left  side  of  the  epiglottis,  amputation 
of  the  left  half  was  performed.  The  physical  evidences  of  pulmonary 
involvement  were  confined  entirely  to  the  upper  portion  of  the  right 
lung. 

The  pathologic  condition  consists  of  superficial  ulceration,  infil- 
tration, deeper  ulceration,  and  tuberculous  new-growths.  One  or  all 
of  these  conditions  may  be  present  in  the  same  larynx.  In  the  majority 
of  cases  infiltration  is  the  earliest  manifestation  of  pathologic  change. 
The  most  frequent  site  of  tuberculous  lesions  is  the  region  of  the  aryte- 
noids and  the  interarytenoiil  commissure.  Lake  reported  this  portion 
of  the  larynx  affected  twice  as  often  as  the  vocal  cords,  and  about  three 
times  as  often  as  the  epiglottis  and  ventricular  bands  (Thompson).  In 
striking  contrast  is  the  experience  of  Gaul,  who  reports,  out  of  113 
cases,  an  involvement  of  the  arytenoids  in  less  than  two-thirds  as 
many  cases  as  of  the  vocal  cords,  and  in  but  little  more  than  one-half 
the  number  affecting  the  epiglottis  (Cornet).  The  consensus  report  of 
many  laryngologists,  however,  indicates  the  preponderance  of  arytenoid 
involvement,  and  the  comparative  infrequency  of  epiglottidean  affection. 
Levy  in  1889  reported,  out  of  144  recorded  cases,  lesions  of  the  epiglottis 
in  but  41.  My  own  observation,  in  a  general  way,  concerning  the  loca- 
tion of  tuberculous  processes  in  the  larynx  among  pulmonary  invalids, 
points  toward  an  apparent  predilection  of  the  infection  for  the  region 
of  the  arj-tenoids.  In  Figs.  127  and  128  are  shown  drawings  of  the 
laryngeal  conditions  in  two  patients  recently  under  observation.  I  have 
noticed  repeatedly  that  cases  of  pronounced  epiglottidean  invasion 
were  those  of  general  miliary  infection,  especially  if  the  local  process 


TUBERCULOSIS    OF   THE    LARYNX 


529 


was  accompanied  by  more  or  less  edema.  In  such  cases  there  were 
often  recognized  small  miliary  tubercles  scattered  over  the  crescentic 
surface.  Fig.  130  represents  a  drawing  of  the  larynx  of  a  patient  who 
succumbed  to  general  miliary  infection. 

While  infiltration  usually  precedes  other  pathologic  changes,  it  may 
be  associated  with  the  formation  of  papillomatous  a:riiwths,  and  finally 
with  varying  degrees  of  ulceration.     I  have  been   iininc^cd  with  the 


:ir 


ulous      in6Itration, 


great  frequency  of  small  cauliflower  excrescences  within  the  inter- 
arytenoid  commissure  among  phthisic-il  |iaiicnt.s,  as  well  as  in  others 
exhibiting  no  evidence  of  tubeiriilnus  inlcction.  Tubercle  bacilli 
are  sometimes  found  at  the  base  of  the  papilloiiiata  after  curetment. 

The  tuberculous  process  within  the  larynx  is  often  roniplicated  by 
varying  degrees  of  mixed  infection.     In  the  case  uf  piinuu-y  disease 


Fig.  129. — Scar  of  tuberculous  ulceration, 
half    of    epiglottis,      nodular         "' 
I  vocal  and  ventricular  bands. 


previously  cited,  the  secondary  infection  was  pronounced,  consisting 
of  many  varieties  of  microorganisms,  the  staphylococcus  and  the  strep- 
tococcus predominating.  In  this  connection  it  is  of  interest  to  consider 
the  possibility  of  secondary  involvement  of  the  lung,  and  the  develop- 
ment therein  of  local  non-tuberculous  processes,  as  a  result  of  extension 
from  the  larynx.  The  downward  bacillary  distribution  may  relate  to 
the  bacteria  of  mixed  infection,  as  well  as  to  tubercle  bacilli.     It  has 


530  COMPLICATIONS 

become  a  matter  of  common  clinical  observation,  as  stated,  that  an 
apparent  primary  tuberculous  deposit  in  the  larynx  is  followed  after  a 
variable  time  by  the  appearance  of  pulmonary  lesions.  Apropos  of 
a  possible  aspiration  infection  in  the  lung,  the  following  case  is  perhaps 
worthy  of  brief  report: 

A  bo}',  thirteen  years  of  age,  the  patient  of  Dr.  Robert  Le\'j',  Dr. 
Henry  Sewall,  and  myself,  was  brought  to  Colorado  in  February,  1906, 
presenting  a  history  of  hoarseness  of  one  year's  duration.  An  utterly 
hopeless  prognosis  was  rendered  on  the  strength  of  an  advanced  laryn- 
geal infection.  The  larynx  was  found  to  present  the  ulcerative  stage 
of  tuberculous  involvement,  and  the  chest  to  exhibit  signs  of  definite 
consolidation  from  the  apex  to  the  third  rib  of  the  right  lung,  with  fine 
clicks  at  the  end  of  inspiration  following  a  cough.  The  afternoon  tem- 
perature averaged  in  the  neighborhood  of  103°  F.  The  amount  of 
expectoration  for  twenty-four  hours  was  from  three  to  four  ounces. 
Despite  the  tuberculous  character  of  the  laryngeal  disturbance  and  the 
pronounced  physical  signs,  the  sputum  was  found  to  contain  no  tubercle 
bacilli  after  exhaustive  examination,  but  pneumococci  were  present  in 
large  numbers.  The  case  is  of  interest  as  illustrating  the  possible 
primary  infection  of  the  larynx,  which,  through  the  dysphagia  induced, 
and  the  consequent  aspiration  of  particles  of  food,  became  responsible 
for  the  subsequent  development  of  a  pulmonary  infection  of  pneu- 
mococcic  origin. 

The  subjective  symptoms  of  tuberculosis  of  the  lar3-nx  consist 
essentially  of  varj'ing  degrees  of  hoarseness  and  dysphagia.  To  these 
may  be  added  an  increased  sensitiveness,  which  is  manifested  bj'  efforts 
to  clear  the  throat  and  by  an  added  tendency  to  cough.  A  not  infre- 
quent symptom  is  pain,  extending  to  the  ears  and  aggravated  upon 
swallowing.     This  is  often  noted  early  in  the  development  of  ulceration. 

While  the  hoarseness  and  dysphagia  constitute  the  most  prominent 
symptoms,  the  former  being  one  of  tlie  earliest  manifestations  of  the 
disease,  man}^  cases  exhibit  considerable  tuberculous  change  within 
the  larynx  prior  to  the  development  of  any  subjective  symptoms 
whatever.  .4  routine  examination  of  the  larynx  should  be  conducted 
from  time  to  time  despite  entire  absence  of  suggestive  symptoms.  In 
this  connection  it  is  important  to  bear  in  mind  the  anatomic  causes  of 
the  voice  impairment  and  of  the  dysphagia. 

Impairment  of  voice  takes  place  as  a  result  of  imperfect  coaptation 
of  the  vocal  cords,  through  involvement  of  the  crico-arytenoid  articu- 
lation, thus  interfering  with  normal  tension  and  producing  deficient  ab- 
duction and  adduction.  Imperfect  approximation  of  the  cords  ma}'  also 
result  from  the  presence  of  papillomatous  growths  in  the  interarytenoid 
commissure.  Irrespective  of  the  movements  of  the  cords,  the  voice 
may  be  impaired  by  thickening  and  ulceration  of  their  free  margins. 
Dysphagia,  on  the  other  hand,  is  produced  by  ulceration  along  the  free 
edge  of  the  epiglottis  and  in  the  aryepiglottic  folds.  Only  in  the 
presence  of  this  condition  is  the  pain  upon  swallowing  actualh"^  acute. 
Difficult  swallowing,  with  sometimes  a  moderate  sensation  of  pain, 
is  experienced  in  case  of  extensive  infiltration  and  ulceration  of  the 
arytenoids.  The  onset  of  laryngeal  dysphagia  is  indeed  a  most  dis- 
tressing symptom,  and  may  also  occur  as  a  result  of  ulceration  of  the 
epiglottis  from  any  cause.  I  have  under  observation  at  present  a  woman, 
in  advanced  pulmonary  phthisis,  who  suffers  considerable  dysphagia 


TUBERCULOSIS    OF    THE    LARYXX  531 

and  dyspnea  from  the  presence  of  a  tuberculous  tumor  in  the  right 
half  of  the  larynx,  involving  the  right  vocal  band  and  the  right  ventric- 
ular band. 

A  considerable  involvement  of  certain  parts  of  the  larynx  may 
exist  without  the  production  of  subjective  symptoms.  This  is  par- 
ticularly true  of  moderate  changes  in  the  ventricular  bands  and  aryte- 
noids. The  hoarseness  may  begin  as  a  slight  change  in  the  quality  or 
timber  of  the  voice,  and  extend  to  the  point  of  complete  aphonia. 
Aside  from  this  impairment  of  the  vocal  sounds,  a  certain  huskiness  or 
interference  with  normal  phonation  may  result  from  the  presence  of 
large  quantities  of  mucus.  It  is  especially  noticeable  among  patients 
afflicted  with  epiglottidean  swelling,  and  is  sometimes  associated  with 
frequent  efforts  to  expel  clear  mucus  of  a  viscid  and  often  ropy  consis- 
tency. It  is  possible  that  the  peculiar  character  of  the  voice  in  such 
cases  may  be  partly  occasioned  by  the  encroachment  of  the  edematous 
epiglottis  into  the  normal  air-chamber,  thus  interfering  with  the  sound 
vib'-ations  and  modifying  their  quality. 

The  dysphagia  may  vary  from  a  sense  of  uneasiness  duiing  the  act 
of  swallowing  to  the  most  acute  suffering.  In  case  of  advanced  ulcera- 
tion and  immobility  of  the  epiglottis,  regurgitation  of  liquids  often 
takes  place  through  the  nostrils.  It  often  happens  that  patients  are 
able  to  swallow  semisolids  when  liquids  are  rejected.  Owing  to  the 
swelling  of  the  epiglottis,  the  aryepiglottic  folds  and  the  arytenoids, 
together  with  the  faulty  muscular  action  from  infiltration,  the  larynx 
is  not  sufficiently  protected  during  the  act  of  deglutition.  Thus  liquids 
having  less  cohesive  property  than  semisolids  readily  find  their  way 
into  the  larynx  at  this  time. 

In  the  event  of  severe  dysphagia  a  degree  of  relief  may  be  secured 
by  taking  food  through  a  tube  with  the  head  lower  than  the  shoulders. 
This  procedure  may  be  undertaken  with  the  patient  reclining  over  the 
edge  of  the  bed,  the  head  being  downward.  The  same  principle  applies 
in  such  cases  as  obtains  at  the  time  of  administration  of  food  following 
the  performance  of  intubation  in  laryngeal  diphtheria. 

Patients  are  able  to  swallow  more  easily  with  the  head  lower  than  the 
body,  because  of  the  fact  that  in  this  position  the  food  is  not  permitted 
to  gravitate  into  the  larynx. 

A  detailed  description  of  the  local  appearances,  revealed  upon  laryn- 
goscopic  examination,  is  scarcely  appropriate  in  a  book  devoted  to 
pulmonary  tuberculosis,  but  the  visual  conditions  are  so  characteristic, 
as  a  rule,  that  a  brief  allusion  to  the  more  important  features  is  in 
order.  Even  before  the  development  of  infiltration  or  of  superficial 
ulceration,  typical  changes  are  observed  in  the  color  of  the  mucous 
membrane,  especially  within  the  interim'  n(  the  larynx.  The  lining 
mucous  membrane  is  more  or  less  pale  or  yrllow  in  appearance,  in  place 
of  the  normal  pink.  The  blanching  of  tlie  membranes  may  persist  in 
some  cases  for  almost  indefinite  periods  without  infiltration  or  ulceration. 
Usually,  however,  minute  yellowish,  opaque  spots  show  through  the 
superficial  epithelial  surface.  Following  a  somewhat  slow  process  of 
softening  and  disintegration,  small  points  of  ulceration  are  observed, 
which  eventually  coalesce  and  form  ulcers  of  varying  size  but  of  shallow 
depth.  Meanwhile  localized  infiltration  frequently  takes  place  in  the 
arytenoids,  which  are  transformed  into  rounded  or  club-shaped  swellings. 
While  one  arytenoid  is  usually  more  infiltrated  than  its  fellow,  it  is 


532  COMPLICATIONS 

somewhat  exceptional  for  the  tuberculous  process  to  be  definitely 
unilateral  as  regards  this  particular  region.  The  papillomatous  excres- 
cences previously  mentioned  are  easil.y  recognized  in  the  posterior 
arytenoid  commissure  during  abduction,  only  to  disappear  from  view 
inthe  act  of  phonation.  For  a  time  the  cords  may  continue  to  present 
a  normal  appearance,  but  in  many  cases  they  exhibit  a  thickening  and 
congestion,  with  here  and  there  a  tiny  ulcer  upon  the  free  edge.  Inden- 
tations maj^  subsequently  form,  or  the  cords  may  become  partially 
obliterated  as  the  result  of  marginal  extension  of  the  initial  ulcerative 
points.  With  the  commencement  of  epiglottic  invoh-ement  authorities 
are  wont  to  describe  a  symmetric  edematous  swelling,  giving  rise  to  a 
so-called  "turban-shaped  epiglottis,"  frequently  studded  with  small 
deposits  of  miliary  tubercle.  This  larj^ngoscopic  image  is  certainly 
pathognomonic  of  07ie  variety  of  epiglottidean  tuberculosis,  which  has 
been  referred  to  as  especialh'  likely  to  accompany  a  general  miliar}- 
involvement.  There  is  often  noted,  however,  a  marked  difference  in 
the  distinguishing  characteristics  of  tuberculosis  of  this  region.  In  the 
finst  place,  the  edema  or  infiltrative  process  may  be  strictly  unilateral. 
There  are,  moreover,  many  cases  of  tuberculosis  of  the  epiglottis  which 
are  not  associated  with  tumefaction  and  congestion,  with  the  formation 
of  miliar}'  tubercles,  or  even  with  points  of  active  ulceration.  I  refer 
to  instances,  often  observed,  of  a  pale,  anemic  epiglottis,  the  crescentic 
margin  of  which  is  somewhat  irregular,  with  a  peculiar  localized  notching, 
at  which  points  the  process  may  perhaps  be  described  as  a  crumb- 
ling, non-inflammatory  disintegration.  Although  considerable  deformity 
sometimes  results,  the  condition  is  usually  attended  by  no  subjective 
manifestations.  In  advanced  cases  of  laryngeal  tuberculosis,  the  con- 
tour of  the  interior  is  greatly  altered,  and  extensive  areas  are  involved 
by  the  ulcerative  processes.  It  is  often  difficult  to  distinguish  between 
the  ulcerative  and  infiltrative  regions,  owing  to  the  close  similarity  of 
their  appearance. 

I  am  cognizant  of  the  many  deficiencies  of  the  foregoing  description 
of  the  visual  appearances  in  laryngeal  tuberculosis,  but  have  endeavored 
in  few  words  to  present  the  subject  from  the  standpoint  of  an  internist, 
rather  than  to  aspire  to  an  elaborate  exposition,  from  a  laryngologic 
point  of  view.  For  this  reason  no  attempt  will  he  made  to  introduce 
elements  of  differential  diagnosis  between  tuberculosis,  syphilis,  lupus, 
perichondritis,  and  malignant  growths,  as  these  considerations  pertain 
not  to  the  complications  of  pulmonary  tuberculosis,  but  strictly  to  the 
domain  of  laryngology. 

The  prognosis  of  laryngeal  tuberculosis  is  a  matter  concerning 
which  clinicians  in  health-resorts  are  enabled  to  form  in  general  fairly 
definite  opinions.  There  has  been  observed  of  late  among  writers  a 
tendency  to  indulge  in  more  or  less  generalization  concerning  this 
subject.  One  very  prominent  author,  from  his  own  experience  and 
that  of  others,  has  recently  asserted  that  the  average  duration  of  life 
following  the  onset  of  pulmonary  tuberculosis  is  three  years,  and  the 
period  after  the  development  of  a  complicating  tul)erculosis  of  the 
larynx,  one  and  one-half  years.  It  must  be  apparent  that  each  case  of 
laryngeal  tuberculosis,  like  the  pulmonary  infection,  must  necessarily 
be  a  law  strictly  unto  itself.  Each  individual  instance  of  this  complica- 
tion, in  accordance  with  the  widely  differing  conditions  in  force,  must 
be  judged  solely  upon  its  own  intrinsic  merits.      I  have  been  privi- 


TUBERCULOSIS    OF    THE    LARYNX  533 

leged  to  observe  very  many  cases  entirely  recover  in  the  hands  of  my 
colleagues,  to  whom  such  patients  were  referred  for  local  treatment. 
In  other  cases  I  have  been  forced  to  witness  a  speedy  termination  in  a 
suprisingly  short  time  after  the  development  of  the  laryngeal  condition. 
Furthermore,  a  few  patients  have  been  observed,  in  whom  recovery 
took  place  spontaneously,  the  improvement  in  the  laryngeal  affection 
developing  pari  passu  with  the  gain  in  the  general  condition.  Heryng 
has  reported  fourteen  cases  in  which  the  healing  was  spontaneous. 

The  prognosis  of  tuberculosis  of  the  larynx  may  be  assumed  to 
vary  according  to  the  state  of  the  general  health;  the  extent  and  degree 
of  activity  of  the  pulmonary  infection;  the  tendency  toward  tissue 
repair,  as  shown  by  the  previous  history;  the  location,  duration,  and 
character  of  the  laryngeal  process;  the  nature  of  the  general  super- 
visory control;  the  skill  and  experience  of  the  laryngologist;  and  the 
personal  equation  of  the  patient  as  regards  temperamental  peculiarities. 
Before  rendering  an  opinion  as  to  the  probable  outcome,  all  the  phases 
of  the  individual  case  should  receive  thoughtful  consideration.  The 
important  bearing  of  the  general  health  and  of  the  condition  of  the 
lungs  upon  the  ultimate  prognosis  is  too  obvious  to  warrant  explanation. 
The  situation  of  the  tuberculous  lesion  is  of  considerable  significance  as 
regards  its  amenability  to  arrest  and  the  degree  of  resulting  functional 
disturbance.  Generally  speaking,  a  tuberculous  deposit  within  the 
larynx  is  possessed  of  much  less  direful  import  than  attaches  to  involve- 
ment of  the  arytenoids,  and  particularly  of  the  epiglottis.  Even  per- 
manent impairment  of  the  voice,  resulting  from  extensive  destructive 
change  involving  the  cords  and  ventricular  bands,  is  assuredly  attended 
by  less  disastrous  consequences  than  follow  the  development  of 
dysphagia.  Aside,  however,  from  the  purely  functional  incapacity, 
an  infection  upon  the  exterior  of  the  larynx  is  more  likely  to  be  of  rapid 
progress  than  within,  and  is  more  frequently  an  accompaniment  of  a 
general  miliary  invasion.  Tuberculous  processes  upon  the  ventricular 
bands  are  usually  slow.  Perhaps  the  one  factor  of  especial  prognostic 
moment  favoring  recovery  is  improvement  in  the  general  condition. 

Treatment. — The  management  of  laryngeal  tuberculosis  must  be 
primarily  directed  toward  a  restoration  of  the  strength  and  powers  of 
resistance.  It  is  questionable  if,  in  a  very  considerable  number  of 
cases,  this  feature  of  treatment  should  not  take  precedence  over  the 
employment  of  local  applications.  Any  desire  to  reflect  upon  the 
utility  of  local  treatment,  for  properly  selected  cases  in  the  hands  of 
competent  laryngologists,  is  emphaticall>  disciaiiiied.  It  is  contended, 
merely,  that  not  every  case  of  laryngiMl  f ulii'iculosis  is  suitable  for 
local  therapeusis.  In  some  patients  the  nnlun-  of  the  tuberculous 
process  is  not  such  as  to  demand  other  tli:ni  lociil  doanliness,  which  can 
be  maintained  at  home  under  proper  iiistiuctions.  In  others,  the 
character  and  extent  of  the  underlying  puhiicniai)-  affection,  with  the 
accompanying  temperature  elevation  and  exhaustion,  are  sufficient  to 
preclude  attention  to  the  larynx,  unless  means  to  conduct  the  treatment 
are  improvised  in  the  home.  Even  among  patients  whose  general 
condition  is  admittedly  less  desperate,  unfortunate  results  often  attend 
the  effort  involved  in  seeking  throat  treatment  at  a  point  necessarily 
remote  from  one's  place  of  temporary  abode.  It  is  probable  that  some 
patients  do  not  secure  results  at  all  commensurate  with  the  expenditure 
of  energy,  the  nervous  excitement,   the  interruption  of  the  outdoor 


534  COMPLICATIONS 

regime,  the  frequent  accession  of  fever,  and  acceleration  of  pulse  con- 
sequent upon  the  journey  to  the  of&ce  of  the  larj-ngologist.  There 
can  be  no  doubt  as  to  the  correctness  of  the  preceding  assertion,  even 
among  invalids  for  whom  local  management  is  actually  indicated  upon 
the  merits  of  the  laryngologic  condition.  Under  such  circumstances 
it  necessarily  becomes  a  choice  of  the  lesser  of  two  evils,  the  decision  as 
to  the  method  of  procedure  demanding  a  wise  discrimination  upon  the 
part  of  an  experienced  clinician. 

There  can  be  no  argument  as  to  the  propriety  of  local  management 
in  cases  of  ulcerative  laryngeal  involvement  among  individuals  whose 
general  condition  does  not  contraindicate  the  effort  required  to  secure 
the  treatment.  Nothing  can  be  more  pitiful,  however,  than  to  witness 
advanced  and  hopeless  consumptives  dragging  themselves  to  a  doctor's 
office  day  after  day  to  receive  a  few  moments  of  laryngologic  attention, 
no  matter  how  skilful  or  rational  the  treatment. 

It  is  not  within  the  scope  of  this  book  to  enter  into  the  details  of  local 
treatment  applicable  to  the  manifold  conditions  present  in  laryngeal 
tuberculosis,  and,  therefore,  but  a  cursory  discussion  of  the  general 
principles  is  appropriate.  The  determination  of  the  particular  form  of 
local  treatment  to  be  accorded  individual  cases  is  entirely  beyond  the 
province  of  the  internist.  The  conservative  judgment  of  the  experi- 
enced laryngologist  as  to  methods  of  application  is  of  far  greater  value 
than  dexterity  of  manipulation.  In  general,  alkaline  cleansing  solutions 
are  indicated  for  any  variety  of  tuberculous  lesions.  Solutions  of 
cocain  and  eucain  are  of  value  in  case  of  painful  deglutition,  or  as  a 
preliminary  to  the  introduction  of  other  preparations.  Levv  frequently 
uses  preparations  of  menthol  which  are  antiseptic,  anesthetic,  and 
stimulant.  He  descriljes  their  effect  "in  relieving  the  pain,  diminishing 
the  cough,  and  giving  the  patient  a  feeling  of  general  well-being." 
Ulcerative  processes  are  variously  treated  by  applications  of  iodoform, 
aristol,  lactic  acid,  nitrate  of  silver,  and  occasionally  by  the  careful  use 
of  the  curet.  Cohen  has  cautioned  against  the  use  of  lactic  acid  unless 
the  mucous  membrane  is  broken,  but  he  believes  it  to  be  of  especial 
value  in  case  of  superficial  ulceration.  It  should  not  be  used  in  excess 
of  80  per  cent,  strength,  anil  usualh'  in  considerably  weaker  solutions. 
Its  efficac)-  depends  upon  the  thoroughness  of  its  application,  which 
in\olves  a  degree  of  rubbing  or  massage.  Dr.  J.  M.  Foster  prefers  a  2 
to  8  per  cent,  aqueous  solution  of  formaldehyd,  which  is  to  be  thoroughly 
rubbed  into  the  ulcers.  For  the  technic  of  the  several  procedures, 
together  with  their  special  indications,  the  reader  is  referred  to  text- 
books upon  laryngology.  In  dismissing  the  subject  of  laryngeal  tuber- 
culosis attention  is  again  called  to  the  paramount  importance  of  general 
management.  The  same  principles  of  climatic,  hygienic,  and  consti- 
tution;il  treatment  apply  as  in  tuberculo.sis  of  glands,  bones,  joints, 
genito-urinary  organs,  and  other  regions  already  described.  It  should 
be  noted,  however,  that  laryngeal  tuberculosis,  more  than  all  other 
complications,  is  apt  to  be  associated  with  considerable  pulmonary 
involvement  and  a  varying  degree  of  functional  derangement,  systemic 
infection,  and  exhaustion.  For  these  reasons  rest,  as  opposed  to  exer- 
cise, should  be  emphatically  enjoined.  Sunshine,  fresh  air,  and  super- 
alimentation are  demanded  even  more,  rigidly  than  in  other  forms  of 
local  tuberculosis.  Favorable  climatic  influences  are  of  special  benefit 
on  account  of  the  improved  nutrition  afforded,  the  increased  facilities 


TUBERCULOSIS    OF    THE    EAR    AND    NOSE  535 

for  outdoor  exercise,  and  the  psychic  effect  of  changed  environment. 
A  tendency  has  been  observed  to  decrj'  the  advantages  of  climate  for 
invahds  suffering  from  any  form  of  laryngeal  tuberculosis.  As  a 
matter  of  fact,  however,  if  the  general  condition  and  the  pulmonary 
infection  are  such  as  to  suggest  the  propriety  of  climatic  change,  the 
existence  of  a  laryngeal  tuberculous  deposit  only  intensifies  the  necessity 
of  prompt  action.  Any  therapeutic  agent  known  to  exert  a  favorable 
influence  upon  the  course  of  the  pulmonary  disease  may  be  expected  to 
exercise  a  corresponding  effect  upon  the  local  condition.  The  existence, 
therefore,  of  vulnerable  tissues  within  the  larynx,  in  association  with 
pulmonary  tuberculosis,  in  the  absence  of  special  contraindications, 
accentuates  the  wisdom  of  early  climatic  change. 


CHAPTER  LXXVIII 
TUBERCULOSIS  OF  THE  EAR  AND  NOSE 

The  frequency  of  purulent  otitis  media  among  pulmonary  invalids 
is  a  matter  of  common  clinical  observation.  The  tuberculous  nature 
of  the  affection  is  demonstrated  by  the  presence  of  bacilli  in  the  secretion 
and  by  the  results  of  autopsy,  the  latter  having  disclosed  tubercle  deposit 
in  the  membrana  tympanum,  the  middle  ear,  and  even  the  inner  ear. 
According  to  James,  Wingrave  found  true  tubercle  bacilli  in  the  purulent 
discharge  of  17  patients  with  middle-ear  disease  out  of  a  total  of  100, 
and  pseudotubercle  bacilli  in  7  cases. 

There  appears  to  be  no  fixed  relation  between  the  activity  or  extent 
of  the  pulmonary  process  and  the  development  of  tuberculous  disease 
in  the  ear.  It  is  generally  believed,  however,  that  the  otitis  is  more 
prone  to  occur  among  advanced  consumptives,  and  to  be  relatively 
infrequent  during  early  stages  of  pulmonary  disease.  As  a  matter  of 
fact,  tuberculosis  of  the  ear  is  comparatively  rare  as  a  clinical  manifesta- 
tion among  rapidly  progressive  cases  of  pulmonary  tuberculosis,  but, 
upon  the  contrary,  develops  somewhat _moi-e  frequently  among  chronic 
invalids  in  whom  the  pulmonary  process  is  more  or  less  stationary. 
It  should  not  be  assumed  that  the  aural  affection  rarely  supervenes 
.during  periods  of  general  or  pulmonary  improvement,  nor  that  a  pre- 
vious otitis  media  invariably  undergoes  a  corresponding  change  for  the 
better  at  such  a  time,  after  the  manner  of  laryngeal  tuberculosis.  It  is 
not  uncommon,  even  among  consumptives  who  have  attained  a  mod- 
erate degree  of  improvement  in  the  general  condition,  with  an  apparent 
quiescence  of  the  tuberculous  infection.  I  have  had  occasion  to  note 
its  occurrence  not  infrequently  among  cases  of  the  fibroid  type,  and  it 
has  appeared  in  some  cases  after  a  complete  arrest  of  the  pulmonary 
infection  has  been  secured.  Several  patients  have  presented  the  history 
of  a  purulent  discharge  of  a  demonstrably  tuberculous  nature  as  the 
first  manifestation  of  tubercle  deposit. 

In  view  of  the  preceding  observations,  it  is  reasonable  to  question 
to  what  extent  the  disease  of  the  ear  is  dependent  upon  the  pulmonary 
infection  per  se.     Unusual  facilities  are  presented  among  consumptives 


636  COMPLICATIONS 

for  the  extension  of  the  tuberculous  infection  to  the  middle  ear,  the 
Eustachian  tubes  constituting  the  medium  of  bacillary  transmission. 
The  orifices  of  the  tubes  are  subject  to  almost  continuous  exposure  to 
infection,  on  account  of  the  frequent  passage  of  sputum  to  the  pharynx, 
and  the  forced  distribution  of  bacilli  to  neighboring  regions  by  violent 
expulsive  cough.  Masses  of  infected  sputum  frequently  become 
adherent  to  the  posterior  wall  of  the  pharynx,  and  remain  for  prolonged 
periods.  This  is  also  true  of  the  nasopharynx,  particularly  with  the 
patient  in  the  recumbent  posture  during  sleep.  Cornet  has  referred 
to  the  statement  of  Dmochowski  concerning  the  difficult  detachment 
of  bacilh  after  their  deposit  upon  the  projectile  lips  of  the  Eustachian 
orifices,  and  to  the  opinion  of  Haberman  that  the  tubes  are  wiiler  in 
consumptives,  by  reason  of  the  greater  absorption  of  fat  and  tissues. 
There  also  exist  among  pulmonary  invalids  certain  other  exciting  and 
aggravating  causes  of  bacillary  extension  to  the  middle  ear.  The 
acts  of  coughing  and  sneezing,  vomiting  and  retching,  so  common 
among  this  class  of  patients,  provide  a  means  of  ready  communication 
to  the  ear  through  a  patulous  tube.  In  this  connection  the  thought 
is  suggested  that  the  violent  paroxysmal  cough,  frequently  observed 
among  cases  of  the  fibroid  or  bronchitic  types,  is  at  least  a  partial 
explanation  of  the  surprising  development  of  ear  tuberculosis  in  patients 
otherwise  maintaining  a  degree  of  improvement. 

The  conveyance  of  tuberculous  infection  to  the  ear  through  the 
tympanum  by  the  introduction  of  contaminated  fingers  and  a  multitude 
of  miscellaneous  articles,  as  claimed  by  various  authors,  although 
accepted  as  a  most  remote  possibility,  is  of  but  slight  practical  interest. 
There  are,  however,  other  sources  of  infection  of  undoubted  importance 
exclusive  of  the  existence  of  pulmonary  tuberculosis.  Purulent  otitis 
media  is  a  not  infrequent  sequel  or  accompaniment  of  cervical  adenitis 
in  children.  In  the  discussion  of  glandular  tuberculosis  it  was  pointed 
out  that  involvement  of  the  cervical  glands  was  often  due  to  an  infection 
traceable  to  the  nose,  mouth,  pharynx,  or  tonsils.  The  development, 
therefore,  of  tuberculosis  of  the  glands  of  the  neck  simultaneously  with 
that  of  the  middle  ear,  in  the  absence  of  pulmonary  disease,  suggests  the 
probability  of  their  common  origin.  Attention  has  been  called  to 
instances  of  tuberculous  infection  of  the  tonsils  and  adenoid  structures, 
which  serve  both  as  receiving  reservoirs  for  bacilli  and  as  points  of 
departure  for  further  dissemination.  The  reports  of  various  observers 
as  to  the  frequency  of  involvement  of  these  tissues  have  been  cited. 
The  faucial  tonsils  and  the  lymphoid  tissues  in  the  nasopharynx  are 
unusually  receptive  to  wandering  bacilli,  by  virtue  of  their  exposed 
position  and  the  anatomic  peculiarity  of  their  construction.  The 
evidence  is  apparently  (•iinclusi\c  (h;i(  iiifcctinii  of  tlicso  parts,  even  in 
the  absence  of  ]niliiiMii:iry  t  iilici-culdsis.  dccui-s  (■(uisiilci-nbly  (iftcner 
than  has  been  supjidscd,  ami  tliat  a  ready  tiaiisniissioii  may  be  effected 
to  the  ear  through  the  Kustachian  tul)C.  Jonathan  Wright  has  repeatedly 
called  attention  to  the  fact  that  various  forms  of  bacteria  are  retained 
upon  the  surface  of  the  epithelial  lining  of  the  tonsillar  crypts,  while 
carmin  granules  and  oily  particles  traverse  the  tissues  without  obstruc- 
tion. He  regards  the  tonsillar  crypts  as  pits  especially  suited  for  the 
lodgment  and  retention  of  tubercle  bacilli.  The  cavities  are  unpro- 
tected by  cilia,  which  serve  to  sweep  away  the  bacteria  in  upper  portions 
of  the  respiratory  tract.     It  is  evident  that  the  tonsils  and  contiguous 


TUBERCULOSIS    OF   THE    EAR    AND    NOSE  537 

areas  are  regions  of  essential  importance  as  regards  the  occasional 
transmission  of  tuberculous  infection  to  various  parts  of  the  body. 

The  origin  of  middle-ear  tuberculosis  is  sometimes  referable  to  a 
distribution  of  the  infective  microorganisms  through  the  circulatory 
channels,  but  this  is,  to  say  the  least,  quite  exceptional,  save  in  cases  of 
general  miliary  infection.  The  development  of  mastoid  involvement 
-without  middle-ear  disease  is  perhaps  suggestive  of  hematogenous 
infection.  The  extension  of  the  tuberculous  process  to  the  mastoid 
follovnng  middle-ear  infection  is  fairly  common,  though  by  no  means 
so  frequent  as  the  secondary  involvement  of  the  mastoid  after  non- 
tuberculous  otitis  media.  Personally,  I  have  observed  but  very  few 
instances  of  mastoid  disease  complicating  middle-ear  tuberculosis  among 
pulmonary  invalids.  Dr.  W.  C.  Bane  reports  that  not  over  3  per  cent, 
of  all  the  cases  of  mastoiditis  operated  by  him  were  of  tuberculous 
origin.  Dr.  J.  M.  Foster,  after  a  careful  review  of  his  cases  submitting 
to  mastoid  operation  during  three  years,  reports  no  single  instance  of 
tuberculous  infection.  As  the  result  of  a  wide  experience,  he  is  inclined 
to  regard  the  tubercle  bacillus  in  the  production  of  mastoiditis  requiring 
operation  as  a  negligible  quantity.  It  is  hard  to  subscribe  to  a  state- 
ment, recently  made,  that  the  common  channel  of  tuberculous  infection 
to  the  meninges  of  the  brain  is  by  way  of  the  ear. 

The  onset  of  otitis  media  among  pulmonary  invalids  is  less  often 
abrupt  or  attended  by  acute  inflammatory  symptoms  than  among 
cases  of  a  non-tuberculous  nature.  An  early  premonitory  symptom  is 
a  sensation  of  slight  fulness  in  one  ear,  and  a  beginning  impairment  of 
the  hearing.  At  times  complaint  is  made  of  pain,  though  this  is  rarely 
extreme,  and  is  much  less  acute  than  in  cases  of  non-tuberculous  otitis 
media.  The  pain,  though  localized  in  the  ear,  frequently  radiates  from 
this  point  to  the  entire  side  of  the  head,  and  there  is  often  present  a 
distinct  throbbing  sensation.  In  the  beginning  there  is  usually  but 
slight,  if  any,  elevation  of  temperature,  thus  differing  from  the  early 
fever  almost  invariably  present  in  ordinary  acute  suppurative  inflamma- 
tions of  the  middle  ear.  With  increasing  distention  of  the  drum,  these 
symptoms,  as  a  rule,  become  correspondingly  more  severe,  while  dizzi- 
ness and  tinnitus  aurium  are  often  distressing  manifestations.  After 
perforation  has  taken  place  a  varying  amount  of  purulent  secretion  is 
discharged.  In  addition  to  tubercle  bacilli  there  is  usually  present  a 
secondary  infection  consisting  of  streptococci,  staphylococci,  or  pneu- 
mococci.  The  pain  in  most  cases  disappears  with  the  appearance  of 
the  discharge,  which,  as  a  rule,  is  non-odorous,  finally  becoming  scanty 
and  of  a  thick,  tenacious  consistency.  This  often  evinces  a  tendency 
to  dry  upon  the  edges  of  the  perforation,  which  in  some  instances  is 
completely  covered,  producing  an  underlying  maceration  of  tissue. 
There  is  usually  a  dulling  and  reddening  of  the  ear-drum  as  a  result  of 
the  inflammatory  change,  and  the  membrane  is  thickened  to  a  con- 
siderable extent.  The  perforation  varies  in  size  and  shape,  sometimes 
an  extensive  area  of  the  membrane  having  been  destroyed.  Necrotic 
changes  in  the  middle  ear  occasionally  supervene,  and  the  process 
continues  to  extend  to  the  destruction  of  the  inner  ear,  involving  the 
labyrinth,  or  spreading  posteriorly  to  the  mastoid.  Fever  is  common, 
as  is  also  a  fetid  discharge.  The  involvement  of  the  mastoid  may  be 
either  chronic  or  acute,  neither  condition,  however,  being  especially 
frequent  in  tuberculous  disease  of  the  middle  ear,  though  possible  of 


538  COMPLICATIONS 

development  as  a  result  of  exposure  to  cold  or  severe  influenza.  In 
this  event  the  pain  becomes  more  pronounced,  but  is  localized  more  or 
less  in  the  mastoid  region  and  aggravated  by  pressure. 

As  a  means  of  prophylaxis,  it  is  important  to  caution  patients 
against  violent  blowing  of  the  nose  or  practising  unconsciously  the 
method  of  Valsalva,  as  thereby  infected  material  is  likely  to  be  intro- 
duced into  the  Eustachian  tubes.  Before  the  stage  of  pus-formation, 
the  treatment  should  consist  of  efforts  toward  maintaining  a  free 
opening  of  the  tube  into  the  middle  ear.  Catheterization  is  indicated 
if  cautiously  performed.  If  fever  is  present,  free  catheterization,  light 
diet,  rest  in  bed,  and  the  administration  of  aconite  or  saline  fever 
mixtures  are  important,  together  with  the  employment  of  leeches, 
either  in  front  of  the  tragus  or  over  the  mastoid.  Irrigation  with  hot 
salt  solution  is  often  attended  by  considerable  relief.  Paracentesis  of 
the  drum  is  indicated  if  bulging  is  prominent.  After  the  perforation 
has  taken  place,  the  chief  effort  should  relate  to  keeping  the  ear  clean 
and  dry.  Routine  irrigation  is  not  recommended,  liut  an  occtisional 
instillation  of  a  cleansing  solution  is  indicated,  followed  bj'  careful 
drying  with  a  pledget  of  cotton.  The  latter  procedure  should  be  prac- 
tised by  the  patient  from  time  to  time.  General  treatment  is  demanded, 
as  in  all  other  forms  of  tuberculosis. 

Another  important  source  of  bacillary  infection  is  found  in  the 
anterior  nares.  Although  tuberculosis  of  the  nasal  cavity  is  extremely 
rare,  the  presence  of  baciUi  in  large  numbers  within  the  nares  is  quite 
common.  The  investigations  of  Straus  several  years  ago,  as  to  the  exist- 
ence of  bacilli  in  the  nostrils  of  healthy  individuals,  attracted  wide-spread 
interest  among  students  of  tuberculosis.  He  demonstrated  virulent 
tubercle  bacilli  in  the  nasal  cavities  in  nine  out  of  twenty-nine  people, 
who  were  brought  into  association  with  consumptives,  br.  Walter  B. 
James  has  reported  the  experience  of  Dr.  W.  Noble  Jones,  who  in  1900 
obtained  a  positive  result  in  10.3  per  cent,  of  cases  from  the  inoculation 
of  guinea-pigs  with  the  nasal  secretions  of  well  people,  who  were  not 
brought  into  intimate  contact  with  pulmonary  invalids. 

Despite  the  occasional  presence  of  bacilli  in  the  nostrils  of  healthy 
persons,  and  the  enormous  invasion  of  the  nasopharj^nx  and  posterior 
nares  among  consumptives  by  reason  of  violent  acts  of  coughing,  but 
comparatively  few  instances  of  primary  tuberculous  infection  of  the 
nasal  mucous  membrane  have  been  recorded.  Willigk,  out  of  1600 
autopsies,  observed  only  a  single  case  of  tubercle  deposit  upon  the  nasal 
septum,  although  450  of  the  subjects  exhibited  evidences  of  pulmo- 
nary disease  (Walsham).  Weichselbaum,  however,  in  146  autopsies 
upon  consumptives,  discovered  two  instances  of  nasal  tuberculosis. 
In  1900  St.  Clair  Thomson  recorded  a  case  of  primary  tuberculosis  of 
the  nose.  Fein  has  recently  reported  a  probable  primary  tuberculosis 
of  one  turbinate  in  a  trained  nurse.  Many  European  observers  have 
cited  similar  cases,  and  Heryng  collected  from  the  literature  a  total  of 
90.  In  1906  Onodi  reported  an  extensive  primary  tuberculous  lesion 
of  the  nasal  septum,  although  there  was  no  clinical  evidence  of  tubercu- 
lous involvement  in  other  parts  of  the  body.  It  is  quite  possible  a  local 
tubercle  tleposit  might  be  discovered  in  more  instances  were  the  char- 
acter of  the  clinical  manifestations  such  as  to  suggest  detailed  inspection. 
I  have  seen  among  pulmonary  invalids  numerous  cases  of  erosion  and 


TUBERCULOSIS    OF    THE    EAR    AND    NOSE  539 

perforation  of  the  septum  supervening  upon  an  initial  slight  excoriation 
of  the  mucous  membrane,  and  attended  by  crust  formation,  but  it  is,  of 
course,  impossible  to  assume  a  tuberculous  involvement  in  such  cases. 
It  is  apparent  that  the  anatomic  structure  and  physiologic  processes 
within  the  nose  jointly  furnish  a  soil  inimical  to  the  growth  and  develop- 
ment of  tubercle  bacilli,  although  these  microorganisms  are  arrested 
in  large  numbers  with  the  inspired  air.  It  would  seem  that  the  element 
of  protection  is  referable  more  to  physiologic  considerations  than  to 
essential  peculiarities  of  anatomic  construction.  The  mucous  membrane 
of  the  nose  is  not  less  permeable  than  that  of  the  pharynx  or  larynx, 
and-  therefore  differences  in  the  susceptibility  of  the  tissues  are  not 
attributable  solely  to  changes  in  the  epithelial  structures,  although  the 
cilia  undoubtedly  exert  a  certain  protective  influence.  The  impene- 
trability of  the  mucosa  by  the  bacilli  is  rather  to  be  ascribed  to  the 
reflex  excitability  of  the  nasal  mucous  membranes,  and  to  the  immediate 
outflow  of  defensive  secretions  upon  the  inhalation  of  foreign  agents. 
For  a  long  time  the  convolutions  of  the  turbinated  bones  were  thought 
to  act  as  a  filter  for  the  bacteria  contained  within  the  inspired  air. 
In  addition  to  the  action  of  the  vibrissse  at  the  entrance  of  the  nostril, 
it  is  known  that  an  extra  amount  of  viscid  fluid  is  secreted  over  the  sur- 
face of  the  convoluted  folds  of  mucous  membrane,  when  irritated  by 
inhaled  dust.  The  bacteria  are  kept  on  the  move  at  least  for  a  consider- 
able distance  through  the  wave-like  motion  of  the  ciliated  epithelium. 
They  are  also  washed  away  from  the  upper  portion  of  the  nose  by  the 
gravitating  serum,  thus  affording  protection  to  the  region  of  the  cribri- 
form plate  of  the  ethmoid. 

It  is  seen,  therefore,  that  in  the  complex  processes  of  infection  and 
immunity  the  cilia  act  in  a  mechanic  way  as  agents  of  defense.  Accord- 
ing to  Wright,  von  Dungern  has  demonstrated  that  the  ciliated  epithelial 
cells  like  the  circulating  cells  in  the  fluids  of  the  organism,  manufacture 
antibodies,  so  that  it  may  be  inferred  that  the  protection  against  infec- 
tion within  the  nose  is  not  entirely  mechanic  in  nature.  Cornet  calls 
attention  to  the  chemic  action  of  the  various  secretions  in  inhibiting 
the  development  of  bacteria,  and  refers,  for  illustrative  purposes,  to  the 
failure  to  secure  pure  cultures  of  pneumococci  in  this  location.  It  does 
not  seem,  however,  that  too  much  influence  should  be  ascribed  to  the 
supposed  chemic  processes  opposed  to  bacterial  growth  in  the  nose. 
If  such  bactericidal  properties  exist  to  any  considerable  extent,  infec- 
tion with  the  diplococcus  meningitidis,  and  its  conveyance  through 
the  cribriform  plate  would  be  decidedly  less  frequent  than  is  actually 
the  case.  It  is  probable  that  the  tubercle  bacilli  are  washed  from  the 
mucous  membrane  by  the  copious  secretions,  and  thus  discharged  from 
time  to  time  without  opportunity  for  prolonged  retention.  It  has  been 
shown  by  Renshaw,  Cornet,  De  Bono,  and  Frisco  that  bacilli  may  gain 
entrance  to  the  lymphatics  through  the  mucous  membrane  of  the  nose 
in  rabbits  and  guinea-pigs,  suggesting  at  least  the  absence  of  bacteri- 
cidal power  in  the  nasal  secretions  of  animals  especially  susceptible 
to  general  infection.  Furthermore,  the  penetration  of  the  membrane, 
and  the  ingress  of  bacilli  into  the  lymphatic  circulation  of  children, 
even  in  the  absence  of  structural  change  of  the  mucosa,  are  suggested  by 
the  development  of  cervical  adenitis.  Several  authors  have  advanced  the 
possibility  of  meningeal  involvement  through  the  medium  of  the  lymph- 
spaces  emanating  from  the  nose.     Irrespective  of  considerations  pertain- 


540  COMPLICATIONS 

ing  to  the  lymphatics,  it  is  easy  to  conceive  of  the  probable  distribution 
of  the  bacilli  from  the  nose  and  nasopharynx  to  the  immediate  region  of 
the  Eustachian  orifices,  with  resulting  disturbance  of  the  middle  ear  as 
the  first  clinical  manifestation  of  the  tuberculous  infection. 

Further  discussion  of  a  subject  so  purely  technical  is  entirely  inap- 
propriate in  a  book  of  this  character. 

Similar  con.siderations  preclude  more  than  the  briefest  possible 
allusion  to  the  various  forms  and  .sites  of  tuberculous  infection  of  the 
eye.  There  is  no  portion  of  this  organ  which  may  not  become  the  seat 
of  tuberculous  involvement.  Tuberculosis  of  the  choroid  was  shown 
by  Cohnheim  in  1867  to  be  in  most  cases  a  local  manifestation  of  a 
general  miliary  infection.  It  is  often  associated  with  meningeal  tuber- 
culosis, and  occasionally  with  a  similar  involvement  of  the  brain. 
Cornet  has  referred  to  the  abundant  blood-supply  of  the  choroid  and 
attributes  to  this  interesting  fact  the  coincidence  of  early  infection  in 
association  with  the  circulatory  distribution  of  bacilli  in  miliary  tuber- 
culosis. The  condition  is  always  bilateral  in  contradistinction  to  a 
unilateral  involvement  in  other  parts  of  the  eye,  in  which  the  infection 
occurs  as  a  result  of  inoculation  or  secondary  extension.  Opportunity 
for  direct  infection  of  the  eye,  and  especially  the  cornea  or  conjunc- 
tiva, would  appear  more  or  less  abundant  among  pulmonary  invalids  on 
account  of  contaminated  fingers,  handkerchiefs,  or  towels.  No  instance, 
however,  of  such  an  occurrence  has  ever  come  under  my  observation, 
but  such  cases  have  been  reported  by  others. 

The  evidences  pointing  to  external  infection  consist  of  the  unilateral 
involvement,  close  association  with  phthisical  invalids  if  the  patient  be 
not  the  subject  of  tuberculosis,  history  of  trauma,  and  absence  of  pre- 
existing foci  of  infection  in  the  immediate  neighborhood.  It  is,  of 
course,  conceivable  that  a  primary  tuberculosis  of  the  cornea  or  of  the 
conjunctiva  may  occur  from  the  entrance  of  infected  dust  or  by  the  dis- 
semination of  bacilli  in  the  act  of  coughing.  The  greater  frequency  of 
conjunctival  tuberculcsis  as  compared  with  corneal  is  no  doubt  explained 
by  the  increased  facility  of  retention  of  microorganisms  upon  the  surface 
of  the  former.  The  removal  of  foci  from  these  parts  is  usually  followed 
by  complete  recovery,  without  a  subsequent  return  of  the  tuberculous 
process.  Many  instances  have  been  reported  of  tuberculosis  of  the 
iris  and  occasionally  the  vitreous,  the  sclera,  retina,  and  lacrimal  sac. 
Verhoeff,  in  the  early  part  of  1907,  reported  some  observations  in  con- 
nection with  tuberculosis  of  the  sclera.  He  regards  scleritis  as  almost 
always  a  tuberculous  process.  He  observed  13  cases  of  this  conchtion, 
in  which  the  diagnosis  was  made  in  all  instances  by  the  tuberculin  test. 
A  general  reaction  was  obtained  in  all  cases  and  a  local  reaction  in  9. 
He  was  unable  to  obtain  evidence  of  systemic  tuberculosis  in  but  3  cases. 


MIXED    INFECTION  541 

SECTION    IX 
Non-tuberculous  .  Complications 


CHAPTER   LXXIX 
MIXED  INFECTION 

Attention  has  been  called  repeatedly  to  the  essential  differences 
observed  in  the  postmortem  findings,  the  symptoms,  clinical  course, 
and  prognosis  of  pulmonary  tuberculosis.  The  absence  of  any  conven- 
tional type,  as  shown  by  the  variety  of  pathologic  conditions  and  the 
modifications  in  the  character  of  the  disease,  is  undoubtedly  dependent 
to  some  extent  upon  the  presence  in  the  tissues  of  pathogenic  bacteria 
in  addition  to  the  tubercle  bacillus.  While  in  many  instances  the 
clinical  manifestations  are  subject  to  considerable  alteration  through 
the  influence  of  pyogenic  microorganisms,  the  evidence  at  hand  is  not 
sufficient  to  permit  the  assumption  of  a  definite  and  invariable  relation 
of  cause  and  effect.  It  is  known  that  many  bacteria  may  exist  within 
the  elementary  tubercle  or  the  surrounding  tissues,  and  be  expelled 
with  the  tuberculous  sputum.  They  are  also  found  upon  mucous  or 
serous  membranes,  upon  walls  of  pulmonary  cavities,  in  organs  of  the 
body  aside  from  the  lungs,  and  sometimes  in  the  blood.  These  micro- 
organisms may  fraternize  with  the  tubercle  bacillus,  forming  a  true 
symbiosis,  the  more  common  forms  being  the  streptococcus,  the  staphy- 
lococcus albus  and  aureus,  the  pneumococcus,  the  influenza  bacillus, 
the  micrococcus  catarrhalis,  and  the  colon  bacillus.  In  addition,  several 
other  species,  notably  the  diphtheria  bacillus,  have  been  reported 
by  observers.  Among  my  own  patients,  the  above-mentioned  micro- 
organisms have  been  found  many  times  in  specimens  of  washed  sputum, 
and  in  several  instances  the  pneumococcus  and  streptococcus  in  the 
blood.  It  is  believed  that,  as  a  general  rule,  in  the  terminal  fevers 
conforming  to  the  septic  type,  the  pus-producing  organisms  are  present 
in  the  pulmonary  tissues,  constituting  a  bacteremia.  The  streptococcus 
has  been  reported  to  be  present  in  miliary  tubercles  before  disintegra- 
tion. 

The  relative  gravity  of  the  mixed  infection  produced  by  the  various 
microorganisms  has  not  been  definileli/  established,  but  in  view  of  the 
fact  that  the  pneumococcus,  staphylococcus,  and  streptococcus  belong 
to  the  well-known  group  of  pathogenic  microorganisms,  it  is  reasonable  to 
assume  a  priori  that  they  are  capable  of  inflicting  great  damage  in  the 
presence  of  pulmonary  lesions.  Many  times  I  have  noted  the  presence 
of  the  pneumococcus  in  connection  with  gross  anatomic  changes  in  the 
pulmonary  tissues,  as  evidenced  upon  physical  examination,  but  have 
observed  that,  as  a  rule,  the  general  systemic  evidences  of  mixed 
infection,  i.  c..  chills,  mental  heljotude,  excessive  emaciation,  and 
general  prostration  are  more  frequent  in  association  with  streptococcic 
or  staphylococcic  infection.  Attempts  to  attribute  the  occurrence  of 
pulmonary  hemorrhage  esseiitially  to  the  action  of  the  pneumococcus 
have  thus  far  not  been  entirely  substantiated.     Both  the  staphylococcus 


542  COMPLICATIONS 

and  the  streptococcus  are  capable  of  producing  severe  constitutional 
disturbance,  the  clinical  condition  being  characterized  bj'  chills,  fever, 
sweats,  rapid  loss  of  weight,  physical  weakness,  and  a  tendency  toward 
cj'anosis,  with  slight  etlema  of  the  face  and  hands.  It  has  rather  been 
my  conclusion  that  the  intellect  is  more  likely  to  be  clouded  in  cases 
of  staphylococcic  infection,  the  mentality  often  being  unaffected  if 
the  streptococcus  is  the  offending  microorganism.  This  clinical  feature 
of  streptococcic  infection  among  pulmonary  invalids  is  somewhat 
surprising  in  view  of  the  well-known  delirium  attending  puerperal 
septicemia,  erysipelas,  and  other  streptococcic  infections.  The  expecto- 
ration attending  the  presence  of  these  pus-producing  microorganisms 
is  profuse,  heavy,  and  usually  of  a  greenish-yellow^  appearance.  Though 
usually  distinctly  purulent  and  raised  with  ease,  it  is  sometimes  decid- 
edly ropy  and  tenacious. 

The  influence  of  the  influenza  bacillus  is  somew-hat  doubtful  as  far 
as  the  destruction  of  tissue  is  concerned,  although  areas  of  broncho- 
pneumonic  consolidation  frequently  result.  As  a  rule,  these  pneumonic 
processes  are  not  of  long  duration,  resolution  taking  place  in  from 
several  days  to  a  few  weeks.  In  exceptional  cases,  however,  I  have 
observed  a  persistence  of  the  consolidation  until  after  the  lapse  of  several 
months,  when  the  physical  evidences  of  the  condition  finally  disappeared. 
A  notable  instance  of  this  condition  is  reported  in  connection  with 
Differential  Diagnosis.  A  pronounced  influenza  infection  is  often 
accompanied  by  increase  of  fever,  malaise,  aching  of  limbs,  impaired 
appetite,  and  aggravation  of  cough,  the  latter  being  more  or  less  paroxys- 
mal in  nature  in  some  cases. 

I  have  found  the  colon  bacillus  very  largely  responsible  for  the 
clinical  symptoms  attending  infection  of  the  genito-urinary  tract,  and 
have  observed  remarkable  improvement  following  the  exhibition  of  a 
colon  bacillus  vaccine  derived  from  the  urine.  Hematuria  and  asso- 
ciated symptoms  suggestive  of  tuberculosis  of  the  kidneys  and  of  other 
portions  of  the  genito-urinary  system  have  entirely  disappeared  under 
treatment  for  the  mixed  infection.  The  reader  is  referred  to  Case  No.  22 
upon  p.  752.  The  nephritic  disturbances  so  common  in  cases  of 
advanced  pulmonary  tuberculosis  undoubtedly  are  produced  in  man}^ 
instances  as  a  result  of  the  multiple  mixed  infections  persisting  during 
indefinite  periods. 

The  clinical  evidence  is  amply  sufficient  to  substantiate  the  belief 
that  a  prolonged  secondary  infection,  though  slight  in  degree,  is  suffi- 
cient to  produce  desquamative  and  degenerative  changes  in  the  kidneys 
of  pulmonary  invalids.  Several  times  I  have  noted  the  development  of 
severe  acute  nephritis  following  a  temporary  streptococcic  infection  of 
the  tonsils.  The  clinical  symptoms  in  these  cases  were  of  so  urgent  a 
nature  as  to  suggest  the  probabilit}'  of  a  general  septicemia.  Chronic 
parenchymatous  nephritis  has  frequently  followed  other  secondary 
infections  if  long  continued,  even  though  apparently  of  slight  severity. 
A  large  number  of  patients  have  developed  well-defined  nephritic 
disturbances,  after  apparent  arrest  of  the  tuberculous  process,  suggesting 
a  possible  relation  between  the  gradual  onset  of  kidney  irritation  and 
the  acquired  immunity  from  the  tuberculous  disease.  It  has  almost 
seemed  in  some  cases  that  the  price  paid  for  the  subsidence  of  the 
activity  of  the  tuberculous  infection  is  the  insidious  development  of 
nephritis.     Irrespective,  however,  of  this  feature  as  applied  to  pul- 


MIXED    INFECTION  543 

monary  invalids  in  general,  it  is  demonstrated  that  kidney  disturbances 
are  much  more  common  in  those  cases  of  pulmonary  tuberculosis 
exhibiting  varying  degrees  of  secondary  infection.  Many  cases  are 
almost  devoid  of  clinical  symptoms,  while  others  exhibit  either  vague 
or  indefinite  manifestations.  A  considerable  number,  however,  present 
symptoms  undoubtedly  due  to  insufficiency  of  the  kidneys,  although 
often  attributed  to  the  effects  of  pulmonary  tuberculosis.  Among  these 
are  included  slight  edema,  rapid  pulse,  varying  degrees  of  dyspnea, 
gastro-intestinal  disturbance,  cyanosis,  and  mild  chronic  uremic 
symptoms.  The  more  common  evidences  suggestive  of  nephritic 
involvement  are  fatigue  and  rapid  pulse.  These  are  often  present  upon 
slight  exertion  in  the  absence  of  all  other  clinical  manifestations  referable 
to  the  kidney  condition.  Dyspnea  is  frequently  out  of  all  proportion  to 
the  amount  of  respiratory  incapacity  occasioned  by  the  pulmonary 
involvement.  Edema  of  the  face,  hands,  feet,  and  ankles  is  also  common, 
as  is  diarrhea,  though  the  latter  is  more  frequently  associated  with 
amyloid  degeneration.  I  have  been  unable,  from  my  own  observations, 
to  ascribe  as  much  significance  to  pain  and  aching  in  the  lower  back  as 
have  other  observers.  The  pulse-rate,  while  abnormally  rapid  in  many 
cases,  is  not  invariably  accompanied  by  an  increase  of  arterial  tension. 
Upon  the  contrary,  it  has  been  my  experience  that  the  blood-pressure 
is  frequently  under  100  in  cases  of  nephritic  involvement  in  the  course 
of  pulmonary  tuberculosis.  Cardiac  murmurs  have  not  been  found 
unduly  frequent  or  possessed  of  special  significance  in  these  cases. 

The  examination  of  the  urine  often  fails  to  disclose  the  presence  of 
large  numbers.  The  albumin,  though  usually  found  in  amj'loid  or 
albumin,  although  hyaline  and  granular  casts  may  be  present  in  very 
advanced  parenchymatous  change,  is,  nevertheless,  absent  in  a  sur- 
prising number  of  cases  in  which  the  casts  show  long-continued  irritative 
and  degenerative  change.  It  is  known  that  among  non-tuberculous 
individuals,  hyaline  and  fine  granular  casts  are  present  in  numerous  cases, 
particularly  during  middle  life  or  later  years,  without  the  slightest  trace 
of  albumin.  They  are  also  observed  in  lithemic  patients,  whose  physical 
exercise  has  been  of  necessity  greatly  restricted  as  a  r&sult  of  the  tuber- 
culous disease.  These  individuals  exhibit  gastro-intestinal  disturbances, 
joint  manifestations,  and  other  evidences  of  impaired  metabolism.  It 
is  not  to  be  supposed  that  the  development  of  kidney  changes  among 
pulmonary  invalids  in  health  resorts  may  be  referred  to  the  influence  of 
high  altitude,  as  some  would  have  us  believe.  Not  infrequently  have  I 
observed  the  nephritic  disturbance  to  improve  materially,  and  even 
to  disappear  altogether  upon  change  of  residence  to  lower  elevations. 
It  is  none  the  less  true,  however,  that  instances  of  similar  improvement 
are  witnessed  in  spite  of  continued  sojourn  in  high  altitudes  and  even  upon 
change  from  sea-level  to  the  elevated  regions  of  Colorado.  Clinical 
evidence  is  assuredly  sufficient  to  refute  statements  that  residence 
in  high  altitudes  tends  to  provoke  kidney  irritation. 

It  is  probable  that  the  toxemia  responsible  for  the  development  of 
nephritis  is  produced,  to  some  extent,  by  the  microorganisms  of  mixed 
infection,  as  well  as  by  the  irritating  products  of  imperfect  metabolism. 
The  precise  pathologic  effect  of  these  microorganisms  upon  the  sub- 
sequent course  of  pulmonary  phthisis  is  not  yet  fully  determined.  That 
a  distinct  modifying  influence  is  produced  by  the  bacteria  of  secondary 
infection  is,  however,  beyond  question.     It  is  well  established  that  the 


544  COMPLICATIONS 

accompanying  bacteria  play  an  important  role  in  the  development  of 
the  pathologic  processes  common  to  pulmonary  tuberculosis,  and  serve 
to  characterize  clinically  certain  phases  of  the  disease,  but  a  clear  and 
accepted  differentiation  of  the  entire  part  assumed  by  the  several 
microorganisms  in  the  pathogenesis  of  consumption  has  not  thus  far 
been  made. 

Some  features  of  mixed  infection  remain  the  subject  of  material 
differences  of  opinion  among  trained  observers.  Many  clinicians  regard 
all  pronounced  temperature  elevations  as  referable  directly  to  the 
action  of  secondary  microorganisms,  while  others  maintain  that  the 
tubercle  bacillus  alone  is  responsible  for  the  fever  of  pulmonary  tuber- 
culosis. A  rational  interpretation  of  the  relation  of  mixed  infection  to 
the  fever  of  phthisis  points  at  least  to  an  appreciable  influence,  in  cases 
of  the  hectic  type,  for  chills,  sweats,  and  prostration,  definitely  charac- 
terize bacterial  infection  of  other  organs  of  the  body.  Upon  the  other 
hand,  manifestations  of  a  like  character  may  apparently  be  produced 
by  the  presence  of  the  tubercle  bacillus  alone.  That  absorption  of  the 
toxins  of  the  bacillus  may  give  rise  to  the  exhibition  of  symptoms, 
simulating  the  septicemia  of  mixed  infection,  is  suggested  by  the  frequent 
results  following  an  administration  of  the  various  preparations  of 
tubercuhn.  It  thus  follows  that  the  so-called  clinical  picture  of  mixed 
infection  is  not  always  produced  solely  by  secondary  microorganisms, 
but  that  it  maj-  result  from  the  action  of  the  tubercle  bacillus  alone  or 
in  combination  with  other  agents  of  bacterial  infection.  The  clinical 
manifestations  of  pure  tuberculous  origin  are  not  essentially  different 
from  those  dependent  upon  mixed  infection,  the  chilly  sensations, 
aching  of  limbs,  sweating,  general  prostration,  and  other  constitutional 
disturbances  being  subject  to  considerable  variation.  It  is  probable, 
however,  that  in  the  majority  of  cases  the  so-called  hectic  fever  of 
phthisis  is  associated  with  a  definite  secondary  infection. 

It  is  generally  believed  that  a  disproportionate  effect  upon  the 
circulatory  apparatus,  reflexes,  and  mental  attitude  is  jjeculiarly 
suggestive  of  the  action  of  the  tubercle  bacilli,  while  excessive  emacia- 
tion and  exhaustion,  violent  cough,  copious  expectoration  in  addition 
to  high  fever,  indicate  a  probable  secondary  infection.  This  relation, 
though  commonly  observed,  does  not  invariabh^  obtain.  Changes  in 
the  mental  condition  and  in  the  character  of  the  circulation  are  by  no 
means  a  constant  accompaniment  of  pure  tulserculous  infection,  and 
often  are  exhibited  in  association  with  other  bacterial  infections,  even 
without  excessive  temperature  elevation.  I  have  repeatedly  observed 
among  consumptives  extreme  mental  hebetude  and  slowness  of  pulse, 
without  fever,  in  connection  with  the  microorganisms  of  mixed  infection. 
In  other  instances  of  secondary  infection  there  may  be  noted  either 
excitability  of  temperament  with  acceleration  of  pulse,  or  depression 
of  spirits  and  melancholia.  It  has  l^een  rather  my  experience  that 
dulling  of  the  intellect,  as  mentioned,  is  particularly  likely  to  occur  in 
cases  of  infection  with  the  staphylococcus  aureus. 

Rapid  emaciation,  violent  cough,  and  profuse  expectoration,  though 
more  likely  to  attend  instances  of  severe  mixed  infection,  nevertheless 
may  exist  in  the  absence  of  such  a  condition.  While  it  is  true  that  the 
breaking  down  of  tuberculous  tissue  is  facilitated  by  the  presence  of 
the  pus-producing  organisms,  yet  the  process  of  softening  and  excava-' 
tion  may  take  place  regardless  of  the  streptococcus  or  staphylococcus. 


MIXED    INFECTION  545 

These  latter  pathogenic  microorganisms  unquestionably  aid  in  the 
disintegration  of  the  tubercles,  and  thus  in  the  exodus  of  the  parasite, 
but  it  is  not  clear  that  they  stimulate  the  growth  of  the  tubercle  bacilli. 
Upon  the  contrary,  despite  the  frequent  urgency  of  symptoms  and  the 
progressive  decline  of  the  invalid,  evidence  is  not  lacking  to  support 
the  theory  that  multiplication  of  the  bacilli  is  sometimes  repressed  by 
the  bacteria  of  secondary  infection,  much  as  the  tubercle  bacilli  are 
annihilated  and  overcome  by  other  bacteria  outside  the  body.  Several 
times  recently  I  have  noted  a  complete  disappearance  of  the  tubercle 
bacilli  from  the  sputum  in  cases  of  severe  mixed  infection. 

The  presence  of  secondary  microorganisms  in  the  sputum  affords 
no  reliable  measure  of  the  severity  of  the  mixed  infection.  In  fact, 
nearly  all  the  bacteria  said  to  be  responsible  for  the  clinical  mani- 
festations of  secondary  infection  may  be  found  in  the  throats  and 
mouths  of  apparently  healthy  people.  The  discovery  of  their  existence 
in  the  sputum  is,  therefore,  robbed  of  a  portion  of  its  special  signifi- 
cance unless  precautions  are  taken  to  avoid  contamination  of  the 
sputum  with  infection  from  the  throat  and  mouth.  For  this  purpose  a 
sterile,  cleansing  mouth-wash  consisting  of  a  saturated  solution  of  boric 
acid  may  be  used  before  the  sputum  is  expectorated.  This  is  washed 
with  sterile  water  and  a  portion  selected  for  examination  from  the 
center  of  the  mass.  Even  after  the  careful  execution  of  these  pre- 
liminary precautions,  the  bacterial  findings  are  not  always  conclusive 
as  regards  the  clinical  severity  of  the  infection.  The  various  bacteria 
of  secondary  infection  may  often  be  found  in  profusion  in  washed 
sputum  in  the  absence  of  the  slightest  clinical  suggestion  of  their  presence 
in  the  tissues. 

A  study  of  the  mixed  infection  of  pulmonary  phthisis  in  connection 
with  the  employment  of  bacterial  vaccines  during  the  past  year  has 
demonstrated  the  surprising  frequency  of  streptococcic,  staphylococcic, 
pneumococcic,  and  influenza  infection,  as  shown  by  the  bacteriologic 
examination  of  the  sputum,  in  the  absence  of  temperature  elevation 
or  of  other  constitutional  symptoms  commonly  associated  with  such 
conditions.  It  also  has  been  of  some  interest  to  note,  as  intimated 
previously,  that,  in  the  majority  of  cases  of  mixed  infection,  particularly 
if  accompanied  by  well-defined  clinical  symptoms,  the  tubercle  bacilli 
have  been  considerably  less  numerous  than  in  instances  of  seemingly 
pure  tuberculous  involvement.  Upon  the  other  hand,  the  characteristic 
constitutional  evidences  of  secondary  infection  are  often  observed  in 
spite  of  failure  to  discover  the  specific  microorganism,  in  the  sputum. 
Inability  to  recognize  the  agents  of  infection  by  a  single  bacteriologic 
examination  should  not  be  construed,  however,  as  negative  evidence. 
It  is  frequently  possible  to  demonstrate  the  bacterial  nature  of  the 
infection  in  doubtful  cases  only  after  very  many  examinations,  both 
microscopic  and  cultural.  In  a  considerable  number  of  cases,  however, 
continued  efforts  toward  the  detection  of  the  microorganisms  remain 
utterly  futile,  even  in  association  with  a  perfect  clinical  picture  of  severe 
secondary  infection.  Thus  it  is  clear  that  clinical  manifestations 
suggesting  the  existence  of  this  condition  may  be  exhibited  in  some 
cases  of  purely  tuberculous  origin,  an  assumption  apparently  confirmed 
by  clinical  experience  and  bacteriologic  investigation. 

The  recognition  of  mixed  infection,  therefore,  is  attained  at  times 
■with  much  difficulty,  its  differentiation  from  miliary  tuberculosis  in 


546  COMPLICATIONS 

particular  often  being  obscure  and  imperfect.  During  a  comparatively 
short  period  of  time  the  symptoms  of  the  two  conditions  may  appear 
practically  identical.  The  recognition  of  the  microorganisms  in  the 
sputum  is  not  of  itself  sufficient  to  establish  definitely  the  diagnosis  of 
a  mixed  infection  as  the  sole  responsible  cause  for  the  clinical  mani- 
festations. As  already  stated,  these  microorganisms  are  sometimes 
found  in  profusion  despite  careful  technic  without  the  advent  of  any 
clinical  symptoms,  and,  further,  the  agents  of  bacterial  infection  in  the 
sputum  may  coexist  with  the  development  of  miliary  tuberculosis. 
It  is  not  always  permissible  in  these  cases  to  reach  a  positive  diagnosis 
of  miliary  tuberculosis  merely  upon  the  exclusion  of  secondary  infection 
as  the  result  of  negative  bacteriologic  examinations.  Upon  the  whole, 
the  diagnosis  of  this  condition  must  be  determined  upon  the  basis  of 
the  principles  previously  enumerated  in  connection  with  miliary  tuber- 
culosis, involving  a  systematic  physical  examination  and  a  well-con- 
sidered analysis  of  all  available  clinical  data.  For  general  purposes, 
it  is  reasonably  safe  to  assume  provisionally  that  the  condition  is  one 
of  mixed  infection,  and  to  recognize  only  the  remote  possibility  of  a 
miliary  involvement,  provided  the  clinical  manifestations  suggestive 
of  the  former  are  reinforced  by  recognition  of  the  microorganisms 
in  the  sputum.  It  is  claimed  that  repeated  observations  of  the  opsonic 
index  may  sometimes  suffice  to  establish  a  definite  diagnosis  in  cases 
previously  admitting  of  reasonable  doubt.  In  the  enthusiasm  attending 
recent  laboratory  aids  to  diagnosis  care  should  be  exercised  not  to 
overlook  important  clinical  features.  The  fever  of  miliary  tuberculosis 
is  not  subject  to  the  same  degree  of  fluctuation  as  that  of  mixed  infec- 
tion, is  less  often  associated  with  chills,  but  is  attended  more  frequently 
by  headache,  dyspnea,  and  mental  symptoms.  With  the  early  develop- 
ment of  motor  disturbances,  discoverable  upon  careful  examination, 
all  possibility  of  error  is  removed. 

Prognosis  of  Mixed  Infections. — The  prognosis  of  all  mixed  infec- 
tions characterized  l)y  clinical  symptoms  is  primarily  identical  with  the 
prognostic  significance  attaching  to  fever,  which  has  been  described. 
The  outlook  for  the  patient  must  be  adjudged  largely  in  accordance 
with  the  principles  outlined  in  connection  with  a  persisting  fever.  The 
prognosis  is  grave  not  merely  from  the  presence  of  fever,  but  from  its 
continuance.  Many  cases  with  long-continued  mixed  infection  of  great 
severity  sometimes  respond  to  appropriate  treatment.  The  prime 
obligation  of  the  medical  attendant  relates,  as  far  as  possible,  to  remedial 
rather  than  palliative  measures.  No  practice  can  be  more  superficial 
than  the  effort  to  lower  temperature  temporarily  through  medicinal  or 
hydrotherapeutic  agencies,  without  immediate  recourse  to  the  employ- 
ment of  other  means  tending  to  prevent  its  recurrence.  Night-sweats, 
diarrhea,  cough,  and  even  hemorrhages  may  be  treated  as  they  arise, 
through  methods  found  to  be  productive  of  temporary  relief,  but  the 
fever  of  sepsis  demands  far  more  than  the  employment  of  measures  to 
increase  the  comfort  of  the  patient.  If  the  policy  of  laissez  /aire  is 
instituted,  the  future  contains  nothing  for  the  patient  but  speedy  disaster. 
If  active  steps  are  taken  to  combat  the  sepsis  of  mixed  infection,  the 
condition  of  the  invalid  is  in  no  wise  made  worse,  even  in  the  event  of 
failure,  and  in  many  cases  the  results  obtained  are  most  gratifying. 
The  measures  which  I  have  been  in  the  habit  of  employing  for  many 
years  are — (1)  The  most  complete  interpretation  of  the  rest  treatment; 


MIXED    INFECTION  547 

(2)  the  use  of  the  antistreptococcic  serum  (now  seldom  used) ;  (3)  during 
the  past  year  the  administration  of  the  bacterial  vaccines  derived  from 
the  sputum  of  the  patient,  as  suggested  by  Wright. 

Management. — The  preliminary  essential  factor  in  the  control  of 
fever  is  red.  Its  effect  is  often  remarkable,  provided  the  invalid  is  kept 
in  bed  at  all  times.  Coincident  with  the  reduction  of  temperature 
there  is  a  corresponding  improvement  of  appetite,  digestion,  and  assimi- 
lation, with  resulting  increased  nutrition  and  greater  powers  of  resistance. 
In  some  cases  the  diminution  of  fever  is  immediate  upon  the  adoption 
of  the  recumbent  position.  There  are  many  patients,  however,  who 
exhibit  at  first  but  slight  subsidence  of  temperature  elevation,  months 
sometimes  elapsing  before  the  fever  recedes  to  the  neighborhood  of 
100°  F.  While  the  prolonged  indefinite  period  of  rest  constitutes  a 
trial  to  one's  patience  and  courage,  the  invalid  is  constantly  laying  the 
foundation  for  a  possible  ultimate  and  complete  recession  to'iKirnial. 
Any  special  deviation  from  the  strict  interpretation  of  tlio  |iriiici|ilos  of 
the  rest  treatment,  even  for  a  short  time,  is  inevitalil}-  drstiiicd  to 
result  in  failure.  This  method  should  be  adopted  ;is  :i  pnlinnnary 
measure  in  all  cases  presenting  the  septic  fever  of  advanced  tuliciciilosis, 
save  in  the  presence  of  such  special  indications  as  (lenKiml  prcnipt 
recourse  to  more  radical  procedures.  Whenever,  from  the  antecedent 
history,  it  is  apparent  that  the  continuance  of  the  rest  treatment  offers 
no  reasonable  assurance  of  success,  refusal  to  resort  to  specific  medica- 
tion, even  if  believed  of  doubtful  utility,  represents,  nevertheless, 
culpable  negligence  on  the  part  of  the  physician. 

In  a  few  cases  conspicuously  gratifying  results  have  been  obtained 
bj'  the  administration  of  the  antistreptococcic  serum.  In  former  years  a 
justification  for  the  employment  of  this  agent,  concerning  which  com- 
paratively little  was  known  and  the  clinical  effects  of  which  were  not 
invariably  favorable,  was  found  in  the  unfortunate  prognostic  import 
of  continued  high  fever.  While  the  rationale  of  its  adniiinstintinn  has 
been  incapable  of  bacteriologic  demonstration,  practical  icsiills,  far 
beyond  the  limits  of  laboratory  knowledge,  were  sometimes  obtained. 
No  medical  growth  can  take  place  without  recourse  to  investigation 
and  experiment.  Development  should  take  place  along  clinical  lines, 
as  well  as  from  the  results  of  laboratory  research.  It  is  known  that  in 
streptococcic  infections  the  toxins  are  not  soluble  in  the  .blood,  but  are 
inclosed  within  the  microorganism  itself,  constituting  an  endotoxin, 
hence  a  neutralization  of  the  toxins,  as  in  tetanus  or  diphtheria,  is 
impossible.  It  has  been  shown  by  Bordet,  von  Lingelsheim,  and  Denys 
that  in  animals,  following  the  administration  of  an  antistreptococcic 
serum,  a  previously  existing  negative  chemotaxis  is  converted  into  a 
positive  one.  As  the  repellant  action  between  the  microorganism  and 
the  leukocytes  is  changed  into  an  attraction,  there  is  afforded  added 
opportunity  for  resulting  destruction  of  the  streptococci  by  the  inglobing 
and  digesting  of  the  microorganisms.  Thus  far  the  results  obtained 
in  animal  experimentation  have  not  been  found  to  hold  true  in  man. 
This  fact,  however,  should  not  be  construed  as  being  sufficient  to  pre- 
clude altogether  the  administration  of  the  sci'iim,  for  the  clinical  evidence 
of  its  value  in  a  small  number  of  cases  a|i|ieais  incontrovertible. 

The  results  of  my  observation  alteraling  the  use  of  the  antistrepto- 
coccic serum  were  reported  five  years  ago.  A  considerable  experience 
since  then  has  emphasized  my  conviction  as  to  its  utility  in  desperate 


548  COMPLICATIONS 

cases,  failing  to  exhibit  improvement  through  other  means.  While 
thoroughly  cognizant  of  some  of  the  disadvantages  attending  its  employ- 
ment, I  have  seen  thus  far  no  valid  reason  to  discountenance  its  tentative 
administration  in  properli/  selected  cases.  The  particular  type  of  cases 
in  which  there  has  been  afforded  a  justification  for  the  use  of  the  serum 
must  be  understood  to  be  that  class  exhibiting  well-defined  clinical 
evidence  of  streptococcic  infection,  substantiated  by  the  presence  of 
the  microorganisms  in  the  sputum  or  blood,  and  associated  with  such 
constitutional  disturbances  as  chills,  irregular  elevations  of  temperature, 
sweats,  and  general  prostration.  Any  physician  having  considerable 
experience  in  the  management  of  tuberculosis,  and  constantly  brought 
into  intimate  association  with  the  disease,  cannot  fail  to  be  impressed 
with  the  great  significance  of  a  pronounced  streptococcic  infection. 
There  is  ever  impressed  upon  the  medical  attendant  an  appreciation  of 
the  disproportion  frequently  existing  between  the  physical  signs  and  the 
general  condition  of  the  patient.  Many  with  comparatively  slight 
activity  of  the  tuberculous  process,  and  with  small  areas  of  pulmonary 
involvement,  in  the  presence  of  this  infection  have  been  forced  to  an 
irresistible  decline.  My  conclusions,  previously  reported,  are  briefly 
summarized  as  follows: 

1.  About  one  case  out  of  every  four  or  five  may  reasonably  be 
expected  to  exhibit  an  appreciable  diminution  of  temperature  by  the 
end  of  a  week  or  ten  days. 

2.  The  remaining  cases  do  not  show  any  bad  results  from  its  employ- 
ment, other  than  the  occasional  intolerance  of  the  system  for  the  serum 
of  the  horse. 

3.  This  so-called  reaction,  which  is  independent  of  the  specific  nature 
of  the  remedy,  but  common  to  all  other  serum  preparations,  bears  no 
relation  to  the  ultimate  results  obtained. 

4.  Some  eases  show  marked  improvement  in  spite  of  temporary 
discomfort  in  the  way  of  chills,  fever,  urticaria,  and  painful  sweUing, 
with  stiffness  of  the  joints,  while  others  exhibit  no  improvement,  although 
there  is  entire  absence  of  constitutional  disturbance. 

5.  Reaction  may  take  place  within  twelve  hours  after  the  use  of  the 
serum,  or  it  may  be  delayed  for  six  weeks. 

6.  Occasionally  the  improvement  is  indefinitely  delayed  until  the 
occurrence  of  the  reaction,  following  which  there  may  be  complete  and 
enduring  subsidence  of  the  fever. 

7.  As  a  result  of  the  serum,  the  temperature  may  either  subside  to 
normal,  or  be  reduced  several  degrees,  remaining,  however,  somewhat 
elevated. 

8.  I  have  not  been  in  favor  of  its  continued  subcutaneous  employ- 
ment, and  have  given,  as  a  rule,  not  over  four  or  five  doses  at  intervals 
of  one  or  two  days. 

9.  I  have  occasionally  practised  the  tentative  administration  of  the 
remedy  by  the  rectum  for  ten  or  twelve  doses  before  resorting  to  its 
hypodermatic  use,  in  order  to  avoid  the  discomfort  which  sometimes 
follows  its  injection  into  the  tissues,  but  have  been  unable  to  secure 
satisfying  results  from  this  method. 

id.  I  have  seen  unquestionable  good  attend  its  u.se  even  when  strep- 
tococci were  not  found  in  the  sputum,  and  believe  that  under  such  con- 
ditions the  clinical  evidences  of  a  persisting  sepsis  may  sometimes  afford, 
from  a  humanitarian  standpoint,  a  warrantable  basis  for  its  use. 


PREGNANCY  549 

Bacterial  Vaccines. — The  foregoing  considerations  pertaining  to  the 
use  of  the  antistreptococcic  serum  are  introduced  in  justification  of 
its  employment  by  physicians,  who  are  unable  to  avail  themselves  of  the 
recent  advantages  offered  by  the  use  of  the  bacterial  vaccines,  to  which 
detailed  reference  will  be  made  in  a  later  chapter.  The  scope  of  their 
application,  particularly  in  connection  with  the  opsonic  index,  is  of 
necessity  greatly  limited  among  general  practitioners  Idv  the  absence 
of  laboratory  equipment  and  training.  Under  such  circumstances 
recourse  to  the  antistreptococcic  serum  in  cases  of  severe  streptococcic 
infection  is  not  only  justified,  but  in  some  cases  demanded. 

The  principles  upon  which  depend  the  elaboration  of  an  artificial 
resistance  to  infection  will  be  discussed  under  the  subject  of  Immunity. 
Through  the  genius  and  indomitable  labor  of  Sir  A.  E.  Wright,  certain 
valuable  contributions  have  been  made  to  the  elucidation  of  the  com- 
plex mechanism  of  immunity.  The  chief  of  these  discoveries  related 
to  an  unsuspected  substance  in  the  blood,  to  which  he  gave  the  term 
"opsonin,"  and  which  was  found  to  act  on  the  bacteria.  It  is  the 
function  of  this  element  to  prepare  the  bacteria  for  inglobing  by  the 
leukocytes.  Wright  found  that  these  opsonins  could  be  increased  in  the 
blood  by  the  introduction  of  cultures  of  dead  bacteria.  Bacteria  suit- 
ably prepared  for  injection  were  called  by  him  "vaccines."  A  descrip- 
tion of  the  preparation  of  vaccines  occurs  in  connection  with  the  Theo- 
ries of  Immunity.  His  elaborate  technic  for  the  precise  determination 
of  the  opsonic  power,  with  reference  to  the  various  forms  of  bacterial 
invasion,  will  be  reviewed  in  detail,  together  with  the  status  of  our 
present  knowledge  regarding  the  principles  of  opsonic  therapy.  The 
practical  application  of  vaccine  therapy  to  cases  of  secondary  infection 
accompanying  pulmonary  tuberculosis  I  have  made  the  subject  of 
considerable  clinical  study.  My  observations  have  been  actuated 
largely  by  reason  of  tlie  frrrpicnt  iinrrUability  of  the  antistreptococcic 
serum  and  its  dtlici'  cil.\-i(nis  ilisinli-dntiif/rs.  An  effort  was  also  made  to 
ascertain,  if  pisssiMc  the  icsulis  id  he  dbtained  from  the  employment  of 
tuberculin  mcilication,  in  cases  of  jjulmonary  tuberculosis  uncomplicated 
by  mixed  infection.  In  view  of  the  fact  that  the  scope  of  my  investiga- 
tion embraced  cases  of  pure  tuberculous  involvement  as  well  as  of 
secondary  infection,  further  discu.ssion  of  the  subject  will  be  reserved 
for  the  consideration  of  Specific  Medication  in  Pulmonary  Tuberculosis. 


CHAPTER  LXXX 
PREGNANCY 


Pregnancy  as  a  complication  of  pulmonary  tuberculosis  is  almost 
universally  believed  to  be  distinctly  detrimental  to  the  health  of  the 
consumptive,  regardless  of  the  extent  or  activity  of  the  disease.  Some 
observers  assert  that  the  harmful  effects  may  be  expected  to  develop 
shortly  after  conception  has  taken  place,  and  continue  without  interrup- 
tion until  the  termination  of  labor  or  convalescence  from  the  puerperal 
period.     The  majority  of  clinicians,  however,  incline  to  the  belief  that 


550  COMPLICATIONS 

the  unfavorable  influence  of  pregnancy  upon  the  course  of  puhnonary 
phthisis  is  exerted  chiefly  after  childbirth.  Nearly  all  agree  that  the 
combined  effect  of  pregnancy,  the  puerperium,  and  lactation  constitute 
a  tremendous  tax  upon  the  physical  energies  of  the  consumptive,  and 
directly  lower  the  powers  of  resistance.  In  view  of  the  clinical  observa- 
tion as  to  the  frequent  increased  activity  of  the  tuberculous  process 
after  childbirth,  with  a  progressive  subsequent  decline,  pregnancy  has 
come  to  be  generally  regarded  as  a  factor  of  grave  prognostic  import 
among  such  patients. 

Instances  of  actual  improvement  in  the  condition  of  the  tuberculous 
lungs  as  a  result  of  concurring  pregnancy  rarely  have  been  recorded. 
It  is  but  natural,  therefore,  that  pulmonary  invalids  should  have  been 
instructed  as  to  the  inadvisability  of  marriage,  the  imperative  avoidance 
of  conception,  and  even  the  expediency  of  a  speedy  termination  of 
pregnancy.  It  is  true  that  a  complete  justification  for  such  advice 
often  obtains  in  special  instances,  when  efforts  toward  the  preservation 
of  the  tuberculous  mother  properly  become  the  paramount  considera- 
tion. It  is  not  invariably  the  case,  however,  that  such  precipitate 
action  is  warranted. 

The  existence  of  pregnancy  per  se,  irrespective  of  important  features 
inherent  to  the  individual  case,  is  not  to  be  regarded  as  necessarily 
inimical  to  the  welfare  of  the  consumptive,  nor  as  prima  facie  justifica- 
tion for  the  performance  of  abortion.  Its  development  among  pul- 
monary invalids  as  a  class  is  assuredly  to  be  deplored,  and  unfortunate 
results  must  of  necessity  be  expected  in  a  large  number  of  cases,  if  the 
pregnancy  is  permitted  to  continue  to  full  term.  It  is  to  be  remembered, 
however,  that  generalizing  statements  concerning  the  influence  of 
pregnancy  upon  consumption  are  not  always  correct  in  their  individual 
application.  As  a  matter  of  fact,  each  case  is  worthy  of  thoughtful, 
well-considered  action  based  upon  the  merits  of  its  several  features. 

The  conditions  obtaining  in  special  cases  may  suggest  the  advis- 
ability of  prolonged,  detailed  observation,  and  in  others  demand  recourse 
to  prompt  and  energetic  measures  in  the  way  of  surgical  relief.  Unfor- 
tunately, the  great  majority  of  cases  are  adjudged  in  accordance  with 
hastily  formed  opinions,  or  even  preconceived  notions  as  to  routine 
principles  of  procedure.  The  practical  lessons  taught  by  a  considerable 
experience  among  such  a  class  of  invalids  are  somewhat  surprising  in 
the  light  of  generally  accepted  views.  No  denial  can  be  made  of  the 
deleterious  effect  of  pregnancy  upon  a  vast  number  of  pulmonary 
invalids,  but  such  influence  is  by  no  means  invariable.  It  is  not  always 
clear  that  the  rapid  progress  of  the  tuberculous  affection  after  childbirth 
is  distinctly  referable  to  the  pregnancy  or  the  puerperal  period. 

It  is  well  known  that  conception  may  take  place  at  almost  any  time 
during  the  course  of  pulmonary  tuberculosis,  even  in  far-advanced 
stages  of  the  disease.  Among  so  desperate  a  class,  a  rapid  progressive- 
deterioration  of  the  physical  condition,  with  a  fatal  termination,  may 
be  reasonably  expected  by  the  end  of  one  year,  with  or  without  the 
added  influence  of  pregnancy.  It  is  thoroughly  substantiated  that 
the  effect  of  pregnancy  upon  the  general  health,  and  the  course  of 
the  pulmonary  involvement  maii  be  decidedl)'  favorable  in  a  few 
instances.  I  have  observed  several  patients  who  presented,  during 
the  entire  period  of  pregnancy,  and  particularly  in  the  earlier  months, 
remarkable    evidences  of  general  and  pulmonary  improvement.     This 


PHEGNANCY  551 

was  often  illustrated  by  increase  of  weight  and  strength,  diminution  of 
cough  and  expectoration,  and  reduction  of  the  temperature.  The 
nausea  and  vomiting  commonly  incident  to  early  pregnancy  are  often 
singularly  lacking  among  consumptives,  thus  precluding'  a  diminu- 
tion in  the  ingestion  of  food  and  the  consecjuent  loss  of  nutrition.  On 
the  contrary,  the  appetite  is  sometimes  enhanced  materially,  and  the 
digestion  unimpaired  or  improved,  with  resulting  gain  in  weight.  It  is 
certainly  true  that  physiologic  processes,  previously  dormant,  are 
often  stimulated  to  such  a  degree  as  to  produce  a  change  in  the  general 
nutrition  of  the  utmost  benefit.  I  have  been  privileged  to  observe  in  a 
few  cases  during  pregnancy,  even  the  complete  disappearance  of  all  the 
subjective  and  physical  evidences  of  pulmonary  tuberculosis,  which 
previously  had  been  persistent  for  several  years.  I  have  in  mind  two 
conspicuous  instances  of  advanced  tuberculous  infection  of  several 
years'  duration,  for  whom  the  development  of  pregnancy  proved  of 
undoubted  benefit.  In  each  case  the  pulmonary  process  became 
entirely  arrested  during  pregnancy,  and  was  not  followed  by  a  renewed 
activity  of  the  infection  after  the  termination  of  labor.  For  the  sake 
of  exactitude  the  two  cases  are  briefly  reported  as  follows: 

Case  1. — A  woman,  twenty-six  years  old,  consulted  me  in  March, 
1901,  two  and  one-half  years  after  arrival  in  Colorado,  and  five  years 
after  the  development  of  pulmonary  tuberculosis.  There  had  taken 
place  a  loss  of  twenty-five  pounds  in  weiglit.  The  cough  and  expectora- 
tion were  moderate,  and  the  general  condition  good.  There  was 
extensive  involvement  of  the  left  lung,  moist  rales  being  readily  de- 
tected upon  easy  respiration  from  apex  to  base,  both  front  and  back, 
with  considerable  consolidation  in  the  upper  portion.  In  the  right 
side  there  was  slight  infiltration  with  moist  rales  at  the  apex.  Bacilli 
were  numerous.  During  the  first  two  years  that  she  remained  under 
my  observation,  in  spite  of  a  material  gain  in  weight,  there  developed 
unmistakable  evidences  of  an  increased  activity  of  the  tuberculous 
process.  The  cough  and  expectoration  perceptibly  increased,  dyspnea 
became  much  more  pronounced,  the  pulse  accelerated,  and  beginning 
physical  evidences  of  cavity  formation  were  recognized  in  the  left  upper 
front.  She  then  became  pregnant,  and  shortly  afterward  suffered  to 
an  unusual  degree  from  nausea  and  vomiting,  until,  at  the  end  of  two 
months,  she  reluctantly  consented  to  the  evacuation  of  the  uterus. 
This  procedure  had  been  advised  from  the  beginning  upon  the  score  of 
the  extensive  active  tuberculous  involvement,  and  the  interference  with 
proper  nutrition.  The  patient  recovered  rapidly  from  the  effects  of 
the  curetment  performed  by  Dr.  W.  S.  Bagot.  At  the  end  of  two 
years  she  again  became  pregnant  and  prompt  interference  was  advised. 
There  had  developed  a  large  cavity  in  the  left  upper  lobe  below  the 
clavicle,  and  moist  rales  were  recognized  throughout  the  left  lung, 
and  in  the  right  apex  to  the  third  rib.  There  was  a  loss  of  ten  or  fifteen 
pounds  in  weight  from  the  normal,  paroxysmal  cough,  copious  expecto- 
ration, slight  temperature  elevation,  and  moderate  dyspnea.  All 
efforts  to  influence  the  patient  to  consent  to  the  termination  of  the 
pregnancy  were  unavailing,  nausea  and  vomiting  being  comparatively 
insignificant.  After  the  second  month  there  ensued  a  diminution  of 
cough  and  expectoration,  and  the  beginning  of  a  remarkable  gain  in 
weight,  which  continued  for  months  after  childbirth.  With  improve- 
ment in  the  general  condition,  there  took  place  a  diminution  in  the 


552  COMPLICATIONS 

activity  of  the  tuberculous  infection,  as  shown  by  the  lessened  amount 
of  moisture  upon  examination.  At  the  expiration  of  her  period  of 
pregnancy  she  had  attained  a  very  material  gain  in  weight,  and 
there  was  an  entire  disappearance  of  cough  and  expectoration.  Fine 
clicks  at  each  apex  were  barely  recognized  at  the  end  of  inspiration 
following  a  cough.  Labor  was  exceedingly  difficult  and  exhausting, 
the  presentation  being  a  breech,  and  the  progress  necessarilj'  slow  in 
spite  of  strong  uterine  contractions.  The  patient  was  not  allowed 
to  nurse  the  child,  nor  to  share  to  any  extent  in  the  responsibilities 
involved  in  the  care  of  the  infant.  The  remarkaV)le  improvement, 
noted  for  the  first  time  during  the  course  of  the  pregnancy,  was  continued 
without  interruption  during  the  following  year.  The  patient  was  per- 
mitted to  return  home  in  1906,  exhibiting  at  that  time,  upon  exami- 
nation, no  evidence  of  any  existing  active  tuberculous  involvement. 
There  was  entire  absence  of  moisture  in  the  finer  bronchi,  as  well  as  of 
cough  and  expectoration.  She  displayed  a  gain  of  fully  fifty  pounds 
in  weight,  and  thus  far  has  suffered  no  relapse.  Upon  the  basis  of  the 
clinical  evidence,  it  is  reasonable  to  assume  that  the  pregnancy  con- 
stituted an  important  factor  in  restoring  the  patient  to  a  life  of  useful- 
ness and  comparative  health. 

Case  2. — A  woman,  aged  twent\--two  years,  consulted  me  imme- 
diately upon  arrival  in  Colorado  in  February,  1903,  three  years  after 
the  development  of  pulmonary  tuberculosis.  There  was  a  loss  of 
thirty  pounds  in  weight  and  an  excessive  cough.  The  expectoration 
amounted  to  eight  ounces  in  twenty-four  hours  and  contained  numerous 
bacilli.  There  were  daily  temperature  elevations  of  two  or  three  degrees 
and  marked  dyspnea.  Examination  disclosed  extensive  active  tuber- 
culous involvement  of  the  left  lung,  with  areas  of  consolidation,  and 
moist  rales  from  apex  to  base,  front  and  back.  A  beginning  tuberculous 
infection  of  the  right  apex  was  noted.  During  the  following  eighteen 
months  there  was  presented  a  progressive  improvement  in  all  respects. 
A  gain  of  forty-five  pounds  in  weight  was  established,  with  correspond- 
ing improvement  in  the  pulmonary  condition.  She  then  moved  to 
another  city  in  Colorado,  and  did  not  come  under  my  observation  again 
until  late  in  1905,  when  she  was  found  to  have  lost  nearly  twenty  pounds 
in  weight,  and  was  experiencing  a  decided  increase  of  the  cough  and 
expectoration.  Upon  examination  moist  rales  were  readily  detected 
from  apex  to  base  upon  the  left  side.  Efforts  to  increase  nutrition  and 
promote  the  general  condition  were  unavailing  until  she  became  preg- 
nant in  the  late  spring  of  1906.  Thereupon  there  developed  a  remark- 
able improvement  in  appetite  and  digestion.  This  was  the  precursor 
of  a  pronounced  gain  in  weight,  with  an  eventual  disappearance  of 
the  cough  and  expectoration.  She  was  examined  in  the  early  fall,  and 
for  the  first  time  since  coming  to  Colorado,  exhibited  an  entire  absence 
of  physical  signs.  The  gain  thus  established  during,  and  presumably 
as  a  result  of,  the  pregnancy  has  been  maintained  to  the  present  time. 

Several  other  cases  have  been  ob.served  which  illustrate  the  coinci- 
dence of  an  undoubted  improvement  in  the  general  condition  and  in 
the  physical  signs  during  the  period  of  pregnancy.  In  these  cases  the 
clinical  data  strongly  suggested  a  relation  of  cause  and  effect.  A  fever 
previously  persistent  has  been  found,  in  exceptional  instances,  to 
disappear  with  the  development  of  pregnancy.  It  is  but  fair  to  state 
that    the   improvement  was  usually   quite  unexpected,  in  some  cases. 


PREGNANCY  553 

premature  delivery  having  been  recommended  and  refused.  It  is 
apparent  that  pregnancy  is  not  always  distinctly  detrimental  to  the 
interests  of  the  consumptive,  that  some  patients  may  secure  a  temporary 
gain  during  the  period  of  gestation,  and  that  a  few  may  derive  per- 
manent benefit  through  its  influence. 

In  addition  to  the  extent,  nature,  and  degree  of  activity  of  the 
tuberculous  lesions,  the  amount  of  fever  and  loss  of  weight  are  ^•itally 
important  considerations  in  the  determination  of  a  rational  course  of 
procedure.  An  essential  feature  is  the  recognition,  during  the  first 
few  months  of  pregnancy,  of  any  appreciable  change  in  the  cough, 
expectoration,  nutrition,  temperature  elevation,  and  physical  signs. 
The  present  nutrition  of  the  invalid,  together  with  the  number  and 
history  of  previous  pregnancies,  must  be  regarded  of  great  importance 
in  estimating  the  probable  influence  to  be  exerted  during  succeeding 
child-bearing  periods.  In  general  it  may  be  assumed  that  greatly 
impaired  nutrition  is  in  itself  a  distinct  contraindication  to  the  con- 
tinuance of  pregnancy.  It  has  been  asserted  by  some  clinicians  that 
repeated  gestations  are  uniformly  productive  of  unfortunate  results. 
I  have  not  found  this  to  be  invariablj'  true.  Several  patients  have  been 
observed,  who  have  apparently  undergone  the  second  and  third 
accouchement  quite  as  well  as  the  first.  The  following  case  is  of  some 
interest: 

A  woman,  thirty-three  years  of  age,  after  three  years'  residence  in 
Colorado,  came  under  my  observation  in  December,  1896,  five  years 
after  the  onset  of  a  tuberculous  infection.  She  was  at  that  time  four 
and  one-half  months  pregnant,  and  had  already  borne  six  children, 
all  living  and  in  good  health.  She  had  done  her  own  housework  in 
addition  to  caring  for  the  children.  There  was  a  loss  of  nearly  twenty 
pounds  in  weight,  slight  cough  and  expectoration,  and  well-defined 
physical  evidences  of  tuberculous  lesions  at  each  apex.  The  confine- 
ment was  normal  and  followed  by  no  appreciable  tendency  toward 
further  decline.  The  patient  eventually  secured  a  complete  and 
permanent  arrest  of  the  tul)erculous  process,  with  disappearance  of 
cough,  expectoratiiui,  and  |)h>sical  si^ns  of  active  infection. 

It  is  a  matter  uf  (•(mm ■liiiical  observation  that  some  patients, 

in  spite  of  impi-nxcnu'iit  duiint::  the  period  of  pregnancy,  exhibit  a 
rapid  decline  following  parturition.  Just  why  this  phenomenon  should 
take  place  is  somewhat  difficult  of  satisfactory  explanation.  It  cannot 
be  that  such  results  are  referaljle  to  the  mere  process  of  labor,  with  its 
attending  pain  and  exhaustion,  for  an  unfavorable  influence  is  not 
infrequently  exerted  even  after  a  brief  and  easy  parturition.  It  is  also 
questionable  if  the  mere  emptying  of  the  uterus  produces  so  complete 
a  change  in  the  physiologic  processes  as  to  bring  about  a  renewed 
activity  of  the  tuberculous  lesions.  It  is  quite  probable  that,  to  some 
extent,  the  unfortunate  clinical  results  are  referable  to  the  burdens  of 
motherhood,  the  frequent  lactation,  the  confinement  to  the  house,  and 
the  added  responsibilities  incident  to  the  care  of  the  child. 

But  slight,  if  any,  unfavorable  effect  of  the  labor  may  be  anticipated 
in  most  cases,  if  the  confinement  is  tcniiiiiatcd  as  quickly  as  possible 
under  the  judicious  employment  of  aiicst  hcsia.  This  should  be  followed 
by  immediate  bandaging  of  the  breasts  and  the  a\(>idance  of  lactation, 
the  placing  of  the  invalid  upon  vigorous  supporting  treatment,  and 
adherence  to  a  rational  system  of  living. 


554  COMPLICATIONS 

It  sometimes  happens  that  a  premature  termination  of  labor  is 
attended  by  distinctly  unfavorable  results,  often  in  excess  of  those 
exhibited  after  normal  parturition.  Patients  presenting  definite 
evidences  of  improvement  during  the  earlier  months  of  pregnancy, 
have  been  observed  to  undergo  a  pronounced  decline  following  an 
accidental  miscarriage.  This  is  referable  in  part  to  excessive  loss  of 
blood  and  the  resulting  exhaustion,  but  a  general  decline  .sometimes 
follows  the  evacuation  of  the  uterus  by  artificial  means.  This  is  much 
less  likely  to  take  place,  however,  following  prompt  and  thorough 
curetment  during  anesthesia,  than  after  tedious  and  painful  methods 
of  producing  abortion.  The  insertion  of  catheters,  bougies,  and  sounds, 
though  sometimes  thought  to  be  indicated  in  cases  of  advanced  phthisis 
on  account  of  objections  to  the  administration  of  an  anesthetic,  is, 
upon  the  whole,  worthy  of  condemnation.  As  stated  in  connection 
with  the  discussion  of  surgical  operations  upon  pulmonary  invalids,  the 
dangers  and  disadvantages  of  anesthesia  to  such  patients  are  greatly 
overestimated.  A  painless  and  speedy  evacuation  of  the  uterus  is 
seldom,  if  ever,  attended  by  unpleasant  results,  while  prolonged  efforts 
to  expel  the  fetus  by  means  of  uterine  contractions,  excited  through  the 
presence  of  a  foreign  body,  are  often  productive  of  serious  hemorrhage 
and  profound  physical  exhaustion.  It  is  chiefly  in  the  latter  class  of 
cases  that  consumptives  are  observed  to  do  badly  following  miscarriage. 
I  recall  the  case  of  a  young  woman  of  twenty-three,  who  came  to  Colorado 
in  1903,  three  months  pregnant,  presenting  the  history  of  a  tuberculous 
infection  immediately  following  a  miscarriage  two  years  previously. 
There  were  excessive  cough  and  copious  expectoration,  moderate  loss 
of  weight,  slight  temperature  elevation,  with  active  tuberculous  infection 
of  the  left  lung  from  apex  to  base,  front  and  back.  Throughout  this 
region  there  were  signs  of  slight  consolidation,  with  moist  rdles  upon 
easy  breathing.  The  patient  exhibited  a  pronounced  improvement 
during  the  first  month  in  Colorado,  there  taking  place  a  diminution  of 
cough  and  expectoration  and  a  materially  improved  nutrition.  Upon 
induction  of  premature  labor  by  the  insertion  of  a  catheter  in  the 
hands  of  a  surgical  colleague,  the  uterus  was  finally  emptied  after  the 
lapse  of  thirty-six  hours.  This  was  followed  by  an  immediate  exacerba- 
tion of  fever  and  other  unfavorable  sj-mptoms,  re])resenting  the  begin- 
ning of  a  relentless  decline,  which  was  terminated  by  her  death  a  few 
months  subsequently.  In  this  instance  the  influence  of  the  pregnancy 
itself  had  not  been  harmful,  but  the  induction  of  premature  labor 
marked  the  onset  of  a  renewed  activity  of  the  tuberculous  process. 

It  is  clear  that  no  general  rule  may  be  formulated  relative  to  the 
effect  of  pregnancy  upon  pulmonary  tuberculosis  which  can  properly 
be  applicable  to  all  cases. 

The  preceding  course  of  remark  is  not  to  be  construed  in  advocacy 
of  an  invariable  continuation  of  pregnancy,  but  more  as  an  emphasis 
to  the  fact  that  the  effect  of  this  condition  is  not  always  detrimental, 
and  that  unfortunate  results  often  attend  precipitate  interference. 


CHAPTER  LXXXI 
SYPHILIS 

The  coexistence  of  sj'philis  and  tuberculosis  is  much  more  frecjuent 
than  generally  supposed,  but  the  precise  relation  of  the  two  infections 
to  each  other  remains  somewhat  doubtful.  The  dual  association  of 
these  diseases,  which  represent  the  two  most  frequent  and  dreaded 
scourges  to  which  mankind  is  subject,  is  of  special  interest  to  the 
clinician  by  virtue  of  tlie  influence  exerted  by  one  infection  upon  the 
other,  and  the  possibilities  of  error  in  the  differential  diagnosis  of 
the  thoracic  manifestations. 

The  common  relation  of  syphilis  to  tuberculosis  consists  of — (1)  the 
influence  of  syphilis  upon  the  vulnerabiUty  of  the  tissues  to  future  tuber- 
culous infection;  (2)  the  effect  of  syphilis  upon  the  course  of  a  previously 
acquired  tuberculosis;  (.3)  the  inodifying  action  of  tuberculosis  upon 
syphilitic  infections  of  remote  and  recent  origin. 

Various  widely  conflicting  views  have  been  expressed  by  observers 
as  to  the  clinical  results  exhibited  by  the  combination  of  the  two  diseases. 
The  somewhat  singular  divergence  of  opinion  is  perhaps  explainable  by 
the  failure  of  clinicians  to  recognize  the  same  essential  differences  of 
classification.  Thus  the  extent  and  character  of  the  influence  exerted 
by  one  infection  upon  the  other  are  dependent  to  a  great  degree  upon 
their  relative  development  in  point  of  time.  It  goes  without  saying, 
moreover,  that  marked  differences  exist  in  the  virulence  of  each  infection. 
Observation  of  a  large  number  of  patients  afflicted  with  both  diseases 
will  necessarily  include  some  presenting  clinical  evidences  of  an  intensely 
virulent  syphilis,  with  comparatively  insignificant  tuberculosis,  and 
others  exhibiting  an  apparently  benign  syphilitic  infection,  with  active 
advancing  tuberculous  processes.  A  progressive  destructive  tendency 
of  both  infections  will  sometimes  be  noted,  while  among  other  individuals 
the  clinical  manifestations  incident  to  both  diseases  are  subject  to  ready 
control. 

Another  important  consideration  is  the  personal  equation,  which 
involves  the  question  of  alcoholism  or  other  excesses,  vigor  of  con- 
stitution, mode  of  life,  occupation,  financial  status,  and  temperamental 
peculiarities,  all  vastly  influencing  the  amenability  to  treatment. 
While  an  arbitrary  classification  of  cases,  therefore,  is  not  permissible, 
certain  liroad  generalizations  are  in  order,  as  evidenced  by  the  results 
of  clinical  (ihservation. 

Hereditary  syphilis  is  known  to  predispose  toward  the  development 
of  tuberculosis.  It  is  natunil  to  suppose  that  the  puny,  ill-nourisheel 
children  of  syphilitic  patents  shduld  exhibit,  as  a  result  of  their  impaired 
vitality,  a  pronounced  diiiiiniilion  of  resistance  to  tuberculous  infection. 
It  has  been  shown  that,  as  I'egards  tuberculosis,  the  influence  of  heredity 
consists  in  most  cases  of  the  transmission  to  the  infant  of  an  enfeebleil 
constitution,  with  impaired  powers  of  resistance  to  tuberculous  infection. 
In  hereditary  syphilis,  however,  a  direct  specific  taint  is  inflicted  upon 
the  child,  but  the  enfeeblement  of  constitution  is  no  less  apparent  than 
in  children  born  of  tuberculous  parents.  It  may  well  be  imagined  that 
the  physical  debility,  retardation  of  growth,  and  imperfect  development 
exhibited  as  a  result  of  infantile  syphilis  are  accompanied  by  a  corres- 


556  COMPLICATIONS 

ponding  weakening  of  tissue  resistance.  Clinical  observation  suggests 
that,  in  addition  to  these  incontestable  factors,  a  direct  predisposing 
influence  to  tuberculosis  is  exerted  by  the  inherited  syphilitic  taint, 
regardless  of  nutrition  or  apparent  vigor  of  constitution. 

It  cannot  be  truly  said  that  tuberculosis  attacks  only  those  syphilitic 
children  who  present  suggestive  manifestations  of  an  inherited  taint. 
I  have  frequently  noted  that  seemingly  healthy  children,  whose  parents 
have  been  admittedly  syphilitic,  after  thriving  for  one  or  two  years, 
suddenly  fall  victims  to  tuberculous  infection.  The  suggestion  derived 
from  such  an  experience,  as  to  the  ultimate  predisposing  influence  of  the 
syphilitic  virus  in  young  children,  is  of  some  interest  in  comparison 
with  the  siirprisingln  few  instances  of  tuberculosis,  observed  among 
children,  one  or  both  of  whose  parents  were  tuberculous  at  the  time  of 
conception.  During  many  years  of  observation  in  a  health  resort  for 
pulmonary  invalids,  comment  has  been  made  repeatedly  upon  the 
comparatively  few  cases  of  tuberculosis  in  childhood,  despite  the  exis- 
tence of  active  infection  in  the  parents  and  of  exceptional  opportunities 
for  acquired  infection  through  almost  wanton  exposure.  Upon  the 
other  hand,  instances  of  tuberculous  development  in  children  have  not 
been  infrequent  when  a  history  of  syphilis  has  been  freely  admitted 
by  a  parent,  or  its  previous  existence  strongly  suspected.  For  the 
foregoing  reasons  it  may  be  accepted  in  general  that  the  transmission  of 
hereditary  syphilis  to  young  children  greatly  increases  the  vulnera- 
bility of  the  tissues  to  tuberculous  infection. 

It  is  also  probable  that  among  3'oung  adults,  the  depressing  influ- 
ence of  acquired  syphilis  increases  to  some  extent  the  susceptibility 
to  tuberculosis.  Instances  of  active  tuberculous  infection,  following 
closely  upon  the  contraction  of  syphilis,  are  not  uncommon.  There 
is  borne  in  mind  the  case  of  a  young  man  who  recently  consulted  me 
presenting  a  history  of  pulmonary  tuberculosis  which  developed  not 
over  two  or  three  months  after  the  appearance  of  the  initial  lesion. 
I  have  observed  several  cases  in  which  the  malnutrition  incident  to 
recent  syphilis  has  appeared  to  favor  predisposition  to  tuberculosis. 
In  such  cases,  if  the  tendency  to  tuberculosis  is  not  directly  augmented 
by  the  syphilitic  taint,  it  is  at  least  clear  that,  thrt)up:h  diminished  resis- 
tance of  the  soil,  a  tuberculous  infection,  previously  latent,  is  brought 
into  renewed  artivity.  Tlie  delotoridus  effect  (if  sy|)hilis  in  its  relation 
to  tuberculous  il,  ninjiin,  nl  is  iVecnieiiily  <u-r(iil iiiili-rl  by  its  influence 
upon  the  skIiskjui  nl  course  n{  the  imliiHUiary  uffei-fion. 

The  advent  of  tuberculous  manifestations  sIkhIIv  after  the  acquire- 
ment of  syphilis  is  often  followed  by  rapidly  a(U-aii(in<i  infection, 
with  a  fatal  termination.  It  is  extremely  doubtful,  howexer,  if  syphilis 
of  long  standing  is  capable  of  exerting  any  special  influence,  either  in 
the  development  or  in  the  course  of  a  later  tuberculous  infection.  It 
has  been  claimed  by  some  that  tuberculosis,  as  a  rule,  exhibits  a  slow 
and  benign  type  among  old  syphilitics.  For  this  reason  a  certain 
retarding  influence  upon  the  evolution  of  tuberculous  changes  has  been 
attributed  to  the  specific  disease.  It  is  quite  likely,  however,  that 
among  such  patients  the  diminished  activity  of  the  tuberculous  infection 
is  dependent  to  some  extent  upon  the  physiologic  conditions  common 
to  more  advanced  adult  life. 

The  influence  of  syphilis  upon  a  previously  acquired  tuber- 
culosis has  seemed  uniformly  unfavorable.     That  extremely  disastrous 


SYPHILIS  557 

consequences  should  follow  the  contraction  of  syphilis  in  the  midst 
of  an  active  tuberculous  involvement  is  perhaps  to  be  expected  on 
account  of  its  profound  constitutional  effect,  together  with  the  added 
element  of  mental  distress.  In  addition  to  the  physical  debility  and 
worry  engendered,  a  not  uncommon  factor  of  unfavorable  moment 
consists  of  the  derangement  of  digestion  occasioned  by  the  necessity  of 
unremitting  medication.  This  is  sometimes  demanded  in  heroic  doses 
almost  regardless  of  stomachic  disturbance.  In  the  majority  of  cases, 
clinical  experience  amply  substantiates  the  unfortunate  effort  of  syphilis 
upon  the  course  of  pulmonary  tuberculosis.  Instances  aic  l«\  no  means 
uncommon,  however,  in  which  the  influence  of  a  .s\  pliilitic  infection, 
ingrafted  upon  an  antecedent  tuberculosis,  has  not  proved  entirely 
unfavorable.  Exceptional  cases  have  been  reported  from  time  to  time, 
showing  a  conspicuous  improvement  stamped  upon  the  clinical  picture 
of  pulmonary  tuberculosis  following  the  combination  of  the  two  infec- 
tions. Several  times  I  have  observed  a  perceptible  change  for  the  better 
in  the  general  aspect  of  the  pulmonary  invalid,  a  few  months  after  the 
development  of  syphilis.  I  recall  the  case  of  a  young  consumptive  of 
twenty-one  who  signally  failed  to  improve  during  six  months'  residence 
in  an  appropriate  climate  under  the  personal  supervision  of  a  skilled 
clinician.  Subsequently  the  patient  came  under  my  observation  shortly 
after  the  development  of  the  initial  lesion.  The  following  appearance 
of  secondary  manifestations  suggested  a  marked  virulence  of  the 
syphilitic  taint.  The  activity  of  the  tuberculous  infection  and  the 
depraved  general  condition,  together  with  the  histor;/  of  a  progressive 
decline,  apparently  suggested  the  utter  hopelessness  of  the  case.  Upon 
the  continued  exhibition  of  specific  medication  an  astonishing  improve- 
ment was  manifested  until  an  entire  arrest  of  the  tuberculous  process 
was  eventually  secured.  In  view  of  the  unfavorable  history,  prior  to 
the  onset  of  syphilis,  the  conclusion  is  possible  that  the  recovery  of  the 
patient  was  largely  influenced  by  the  development  of  the  later  infec- 
tion. While  in  such  cases  complete  proof  is  necessarily  lacking  to  estab- 
lish a  direct  antagonistic  influence  of  the  syphilitic  upon  the  tuberculous 
infection,  the  evidence  appears  conclusive  that  fibrosis  is  occasionally 
favored  to  some  extent  following  the  continued  exhibition  of  specific 
medication. 

The  modifying  action  of  tuberculosis  upon  an  already  existing 
syphilitic  taint  is  also  worthy  of  consideration  by  careful  therapeutists. 
Many  times  I  have  been  surprised  by  the  reappearance  of  syphilitic  mani- 
festations among  consumptives,  who  presented  the  history  of  a  more  or 
less  remote  specific  infection  and  a  prolonged  period  of  rational  medi- 
cation. The  previous  quiescence  of  the  clinical  manifestations  in  such 
cases  suggests  a  complete  control  of  the  infection  for  several  years  pre- 
ceding the  development  of  pulmonary  tuberculosis.  Upon  the  advent, 
however,  of  the  latter  disease,  the  physical  debility  and  emaciation 
undoubtedly  became  instrumental  factors  in  the  recurrence  of  syphilitic 
symptoms.  These  have  usually  appeared  as  local  lesions  upon  the  skin 
or  in  the  throat.  Several  well-defined  cases  of  cerebral  syphilis  have 
been  ob-served  among  my  pulmonary  invalids,  who,  through  habits  of  dis- 
sipation, or  by  virtue  of  other  excesses,  were  unable  to  attain  satisfac- 
tory progress  in  the  effort  to  improve  nutrition.  The  thought  has  been 
suggested  that  the  appearance  of  the  tuberculosyphilids  and  the  hybrid 
affections  of  the  larynx,  pharynx,  or  tongue  in  some  cases  is  due  to  the 


558  COMPLICATIONS 

influence  of  the  tuberculous  infection,  with  its  attending  debility  and  mal- 
nutrition in  arousing  a  dormant  syphilitic  taint.  It  is  believed  by  laryn- 
gologists  that  the  tendency  to  tubercle  is  favored  by  previous  syphilis 
of  the  larynx,  and  it  does  not  appear  unreasonable  to  suppose  that  the 
implantation  of  tubercle  bacilli  upon  a  syphilitic  soil  should  result  in  the 
development  of  lesions  exhibiting  to  some  extent  the  appearance  of  each 
infection.  Marshall  and  other  syphilographers  have  called  attention  to 
the  frequent  erroneous  construction  placed  upon  the  presence  of  tubercle 
bacilli  in  lesions  of  doubtful  character.  When  the  nature  of  the  local 
manifestations  are  such  as  to  render  obscure  the  origin  of  the  infection, 
the  presence  of  tubercle  bacilli  in  the  scrapings  does  not  constitute  po.si- 
tive  evidence  as  to  a  sole  tuberculous  origin.  Aside,  however,  from  the 
direct  ingrafting  of  tuberculosis  upon  local  areas  of  syphilitic  infection, 
evidence  is  not  wanting,  as  stated,  to  substantiate  the  influence  of  tuber- 
culosis, with  its  accompanving  constitutional  impairment,  in  favoring 
the  reappearance  of  specific  lesions. 

The  differential  diagnosis  of  .syphilis  exhibiting  well-defined  thora- 
cic manifestations  and  pulmonary  tuberculosis  is  often  exceedingly 
obscure.  A  close  similarity  is  not  infrequently  observed  in  the  subjec- 
tive symptoms  and  physical  signs.  This  resemblance  may  include  the 
methods  of  onset,  the  existence  of  cough,  expectoration,  emaciation, 
fever;  and  the  physical  evidences  of  consolidation,  softening,  cavity  for- 
mation, chronic  bronchiectases,  or  fibrosis. 

In  many  cases  of  pulmonary  syphilis,  the  clinical  picture  is,  in  fact, 
identical  with  that  of  pulmonary  tuberculosis  save  for  the  absence  of  tuber- 
cle bacilli  in  the  expectoration.  Without  search  for  tubercle  bacilli  no 
suspicion,  as  a  rule,  is  entertained  by  the  physician  as  to  the  character  of 
the  infection.  When  the  examination  of  the  sputum  is  not  practised  as  a 
routine  measure,  it  is  inevitable  that  cases  of  pulmonary  syphilis  will  be 
overlooked,  and  that  patients  will  be  sent  to  climatic  resorts  with  a  diag- 
nosis of  tuberculosis.  I  have  observed  a  few  patients  of  this  class  in  whom 
suspicion  as  to  the  syphilitic  nature  of  the  infection  was  aroused  by  the 
absence  of  bacilli,  and  confirmed  by  the  application  of  the  therapeutic 
test.  The  presence  of  tuliercle  l>a(illi  in  the  sputum  is  not  alwaj^s 
sufficient  to  exclude  entirely  the  .sypliilitic  origin  of  the  pulmonary  con- 
dition. Several  times  I  have  hatl  occasion  to  note  the  remarkable 
paucity  of  tubercle  bacilli,  although  present  after  long  searching,  in 
patients  exhibiting  characteristic  subjective  and  objective  signs  of  an 
active  pulmonary  tuberculosis.  A  disproportionately  small  number  of 
bacilli  contained  in  the  copious  expectoration  of  an  intractable  bron- 
chitis or  in  the  presence  of  pulmonary  excavation  should  awaken  sus- 
picion as  to  the  possible  underlying  syphilitic  nature  of  the  infection, 
upon  which  an  incipient  tuberculosis  may  have  been  ingrafted.  The  same 
is  true  of  an  absence  or  a  pronounced  scarcity  of  bacilli  accompanying 
extensive  fibrosis.  While  the  evidence  in  these  cases  is  by  no  means 
conclusive,  the  wisdom  of  a  searching  inquiry  to  secure  either  the  ad- 
mission of  !33^philis  or  the  recognition  of  other  manifestations  is  appar- 
ent. It  should  be  emphasized  that  syphilitic  dlMa-c  df  ilu-  lung,  either 
alone  or  in  combination  with  tuberculosis,  is  far  iii"ic  Ik^iik  m  thanpi'ac- 
titioners  have  been  prone  to  acknowledge.  Gpiiiiall\  sjk  akmg,  in  pure 
pulmonary  syphilis  there  is  less  tendency  to  temjjerature  elevation  than 
in  tuberculosis,  less  diarrhea,  irritability,  and  acceleration  of  the  pulse, 
night-sweats,  or  emaciation.     In  other  words,  syphilis,  as  a  rule,  is  less 


SYPHILIS  559 

frequently  associated  with  mixed  infection  than  is  tuberculosis,  which 
accounts  for  the  diminished  temperature  elevation  and  the  usual  absence 
of  septic  symptoms  in  the  former  disease.  It  is  true,  however,  that 
some  cases  are  observed  in  which  the  temperature  elevation  is  quite 
out  of  proportion  to  the  degree  of  pulmonary  involvement.  The  per- 
sistence of  fever,  despite  a  prolonged  maintenance  of  systematic  man- 
agement in  cases  exhibiting  exceedingly  incipient  infection,  is  sometimes 
suggestive  of  the  possibility  of  a  syphilitic  taint. 

The  course  of  pulmonary  syphilis  is  often  protracted  to  a  degree, 
patients  sometimes  exhibiting  an  astonishing  tolerance  for  the  infec- 
tion in  the  presence  of  extensive  structural  change.  In  doubtful  cases 
recourse  should  be  taken  to  the  tentative  employment  of  antisyphilitic 
treatment  and  the  specific  medication  subsequently  increased  according 
to  the  therapeutic  indications.  The  relation  of  pulmonary  syphilis  and 
tuberculosis  is  further  discussed  on  page  296. 


PART  VI 

PROPHYLAXIS,  GENERAL  TREATMENT,  AND  SPECIFIC 
TREATMENT 


SECTION    I 
Prophylaxis 

chapter  lxxxii 
reciprocal  relations  of  consumptives  and 

SOQETY 

No  argument  is  needed  to  substantiate  the  assertion  that  the  pre- 
vention of  consumption  has  been  for  years  the  most  vital  sociologic  and 
economic  problem  of  all  civilized  races.  The  wide-spread  distribution 
of  the  disease  among  the  masses,  the  peculiar  conditions  under  which  it 
is  disseminated,  its  high  rate  of  mortality,  its  demonstrable  preventa- 
bility  and  curability,  all  furnish  convincing  testimony  as  to  the  over- 
whelming necessity  of  aggressive  effort  toward  its  limitation  and  con- 
trol. 

The  former  apathetic  recognition  of  the  direful  significance  of  con- 
sumption has  been  supplemented,  during  the  past  decade  and  a  half, 
by  an  active  educational  and  governmental  agitation  throughout  the 
world  toward  its  restriction.  As  a  result  of  the  energetic  campaign 
already  instituted,  the  way  has  been  prepared  for  the  irresistible  advance 
of  the  organized  forces  of  prevention  against  this  common  enemy  of 
mankind.  The  ravages  of  a  veritable  scourge  are  becoming  diminished, 
and  hope  may  perhaps  be  entertained  of  a  complete  subsidence  of  the 
disease,  as  obtained  in  Europe  with  leprosy,  a  kindred  affection,  after 
the  middle  ages.  A  great  deal  that  is  highly  commendable  and  fraught 
with  far-reaching  beneficent  results  has  been  accomplished,  but  there 
remains  much  to  engross  the  attention  and  stimulate  the  activities  of 
phthisiosociologists.  The  present  status  of  the  crusade  against  tuber- 
culosis is  too  well  known  to  clinicians  and  students  of  economic  con- 
ditions to  warrant  repetition.  Recent  literature  has  been  replete  with 
the  reports  of  the  proceedings  of  societies  for  the  prevention  of  consump- 
tion, suggestions  concerning  the  .social  asjjpcts  of  the  disease,  advices 
as  to  its  administrative  control,  recomiiiciKhitinn^  fcgarding  the  best 
manner  of  conducting  an  educational  pr(i]i.iL;:iiiil:i,  k  pcnts  of  committees 
authorized  to  investigate  conditions,  reitciatidiis  of  important  individual 
precautions,  and  finally  personal  appeals  from  essayists  in  advocacy  of 
more  or  less  coercive  measures  of  prevention. 


RECIPROCAL    RELATIONS    OF    CONSUMPTIVES    AND    SOCIETY  561 

In  a  work  devoted  essentially  to  the  clinical  rather  than  to  the  social 
features  of  tuberculosis,  it  is  idle  to  attempt  an  exhaustive  consider- 
ation of  the  many  aspects  of  general  and  individual  proph^daxis.  The 
academic  recital  of  the  almost  infinite  phases  of  the  problem  of  pre- 
vention, even  if,  perchance,  not  entirely  familiar  to  a  portion  of  the 
readers,  would  scarcely  fall  within  the  scope  of  this  book,  as  the  tedious 
details  of  such  an  inquiry  do  not  entirely  harmonize  with  a  predomi- 
nating endeavor  toward  clinical  study. 

It  is  designed  to  present  a  brief  exposition  of  the  trend  of  recent 
prophylactic  endeavor,  to  review  the  generally  accepted  preventive 
measures  pertaining  to  society,  as  well  as  to  the  individual,  and  to 
call  attention  primarily  to  the  trust  imposed  ujion  the  jnmihj  phii- 
sician,  who  constitutes  by  far  the  most  responsible  (ujinl  jar  Ihr  nsiiii-iiini 
and  control  of  consumption.  It  also  is  desired  to  cnipliusizc,  both  upon 
humanitarian  and  economic  groniuls,  the  obligation  of  the  professi(jn 
and  of  society  toward  those  (ilnvdij  afflicted  with  the  disease,  no  less 
than  toward  the  body  pulitir.  Tliis  phase  of  the  subject  has  hitherto 
received  but  comparatively  little  attention.  During  recent  years  the 
organized  work  of  antituberculosis  associations  has  been  devoted 
chiefly  to  the  awakening  of  public  interest  and  the  adoption  of  effective 
prophylactic  measures.  Such  laudable  efforts,  wherever  systematically 
conducted,  have  resulted  in  a  reduction  of  the  mortality-rate  and  in 
the  education  of  society  to  a  more  or  less  intelligent  conception  of  the 
nature  of  the  affection.  While  this  inures  greatly  to  the  piotpction  of 
future  communities,  to  what  extent  the  welfare  of  the  eiiiisinnprn-r  is 
being  subserved  by  concerted  medical  interest  is  justly  suljjcct  1 1  >  iiu  niii  y . 

It  is  apparent  that  the  recent  Tphthisiotherapeutic  thought  has  been 
directed  very  largely  to  the  interests  of  pulmonary  invalids  included  in 
the  category  of  incipient  cases,  to  whom  alone  are  offered  a  welcome  in 
most  institutions  supported  by  private  and  public  benevolence.  With  no 
desire  to  reflect  upon  the  great  utility  of  such  sanatoria  open  to  very 
early  cases,  it  is  none  the  less  opportune  to  mention  the  fact  that  patients 
of  this  character  do  not  constitute  such  a  menace  to  society  as  the  more 
advanced  cases,  and  demand  far  less  the  personal  supervision  of  a  resi- 
dent physician,  with  his  retinue  of  subordinates.  While  an  elaborate 
systematic  control  is  often  accorded  to  incipient  cases,  and  incidentally 
unusual  facilities  for  recovery,  the  same  practical  and  sympathetic 
consideration  is  not  extended  to  those  exhibiting  more  pronounced 
infection.  Advanced  cases  are  denied  admission  to  nearly  all  sanatoria 
and  are  also  persona  non  grata  to  all  municipal  hospitals.  It  cannot  be 
doubted  that  these  unfortunates  should  be  permitted  to  profit  from 
the  recent  agitation  concerning  consumption.  While  they  are  privi- 
leged to  be  registered  at  headquarters  and  to  receive  instructions  from 
some  responsible  medical  source,  they  are  forced  to  appreciate  the  fact 
that  they  constitute  a  source  of  immediate  danger  to  other  members 
of  the  family.  These  invalids,  by  virtue  of  their  advanced  condition, 
are  denied  those  advantages  which  are  freely  bestowed  upon  others, 
who  are  less  worth;/  upon  the  score  of  their  actual  needs,  and  con- 
stitute, to  a  subordinate  extent,  elements  of  danger  to  the  public.  In 
this  connection  let  it  be  understood  that  it  is  the  consumptive,  with 
unmistakable  evidences  of  advanced  infection,  who  represents  the  chief 
source  of  further  bacillary  distribution.  It  is  for  such  individuals  espe- 
cially that  disciplinary  control  is  indicated  and  for  whom  instructions 


562  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

should  be  provided.  Proper  efforts  addressed  to  invalids  of  this  class 
cannot  fail  to  yield  a  satisfactory  return. 

The  practical  results  possible  of  attainment  in  the  effort  to  restrict 
tuberculosis  must  depend  to  a  great  extent  upon  the  willing,  intelligent 
cooperation  of  the  patient.  Public  protection  can  never  be  secured 
in  jull  through  legislative  enactment,  or  attempts  toward  municipal 
control,  unless  the  invalid  from  whom  emanate  the  agents  of  infection 
strives  conscientioushj  to  perjorm  his  part.  Faithful  service  in  this 
respect,  even  in  the  absence  of  a  suitable  environment,  may  be  obtained 
by  instructive  persuasive  appeals,  reinforced,  when  necessary,  by  drastic 
expedients  for  the  ignorant  or  \-icious.  Any  action  bearing  upon  the 
preservation  of  the  public  from  tuberculosis  should  be  attended  by  an 
effort  to  promote  the  welfare  of  the  coiiMiinpiixc  (  h;  s,  especially  among 
the  poor.  This  involves  the  rendering  of  ■^ul>.-^h'iili<il  did  to  those  exhibi- 
ting reasonable  prospects  of  recovery,  and  adet|uate  provision  for  the 
care  and  mairitenance  of  advanced  cases.  At  the  same  time  the  interests 
of  the  community  pertain  to  the  removal,  from  its  very  midst,  of  desti- 
tute invalids  constituting  an  oppressive  burden  to  their  families,  if  not 
to  society,  and  who,  through  their  ignorance  and  inaliility  to  ob.^erve 
precautions,  become  a  constant  menace  to  the  well.  Thel'e  is  demanded 
some  well-directed  and  far-reaching  system  of  education  and  control 
the  influence  of  which,  to  be  most  effective,  must  be  through  the  medium 
of  daily  example  and  priictical  supervision.  It  is  with  reference  to  these 
broad  considerations  that  certain  fundamental  data  of  an  etiologic 
nature  are  adduced  to  demonstrate  the  general  principles  which  should 
govern  a  systematic  prophylaxis. 

Our  present  conception  of  the  etiology  and  pathologj^  of  phthisis 
establishes  conclusively  its  communicability,  preventability,  and 
curability. 

Consumption  is  communicable  only  within  certain  broad  limits. 
Its  transmission  from  one  person  to  another  does  not  take  place  as 
a  result  of  direct  exposure  after  the  manner  of  a  few  contagious  diseases. 
Infection  results  not  from  the  mere  presence  of  the  pulmonary  invalid, 
but  solely  from  neglect  to  observe  necessary  precautions.  A  wide 
dissemination  of  the  bacillus  constitutes  a  source  of  danger  chieflj^  to 
those  rendered  susceptible  by  virtue  of  age,  environment,  occupation, 
previous  disease,  and  other  predisposing  causes.  Thus,  in  the  develop- 
ment of  tuberculosis,  the  character  of  the  soil  as  an  etiologic  factor 
is  equallj',  if  not  more,  important  than  the  presence  of  the  micro- 
organisms. The  development  of  the  disease  is  known  to  be  exceed- 
ingly slow  and  incremental  in  character,  and  only  after  repeated  infec- 
tions have  been  acquired  and  the  individual  resistance  perceptibly 
lowered,  are  recognized  the  clinical  manifestations  of  the  disease. 

As  consumption  is  known  to  Ije  preventable  to  a  great  extent,  there 
is  imposed  a  direct  obligation  upon  society  to  secure  all  possible  means 
of  prevention.  It  is  primarily  essential  that  uniformity  of  method 
be  instituted  as  far  as  practicable  in  different  parts  of  the  country. 
Adherence  to  a  general  concerted  plan  of  action,  representing  botli  an 
active  educational  propaganda  and  a  campaign  of  responsible  control 
should  prove  peculiarly  effective  and  without  prejudice  to  invalids  or 
localities.  The  responsibility  for  the  prevention  of  consumption  rests 
directly  with  the  medical  profession  in  its  advisory  capacity  on  matters 
pertaining  to  public  health.     The  phj-sician,  however,  in  the  execution 


RECIPROCAL    RELATIONS    OF    CONSUMPTIVES    AND    SOCIETY  563 

of  SO  responsible  a  trust,  should  be  mindful  of  his  duty  to  consumptives 
as  well  as  to  society.  Fortunately,  a  sustained  and  conservative  regard 
for  the  rights  and  requirements  of  each  class  need  inflict  no  hardship  upon 
the  other.  Their  interests,  though  apparently  somewhat  divergent,  are, 
as  a  matter  of  fact,  almost  identical,  permitting  relations  of  important 
reciprocity.  It  is  incumliont  upon  the  medical  profession  to  recognize 
the  claims  which  each  lias  u|iciii  the  other,  to  adjust  apparent  differences 
and  insure  the  adopt imi  ami  clTcetive  execution  of  rational  measures 
pertaining  to  inspection  and  control. 

A  proper  administrative  supervision  tends  to  create  among  the  masses 
a  just  conception  of  the  manner  in  which  the  infection  may  be  conveyed, 
a  comprehension  of  the  comparatively  slight  dangers  if  ordinary  pre- 
cautions are  observed,  but  an  acute  appreciation  of  the  necessity  of 
complying  with  detailed  instructions.  A  diffusion  of  elementary 
knowledge  regarding  the  more  important  etiologic  features  of  consump- 
tion is  demanded,  on  account  of  the  frequent  display  of  apathetic 
indifference  or  ignorance,  and  the  occasional  exhibition  of  an  immoderate 
popular  attitude.  The  advocacy  of  such  extreme  procedures  as  the 
obligatory  isolation  and  segregation  of  consumptives,  the  placarding 
of  houses,  the  enactment  of  laws  prohibiting  marriage,  the  compulsory 
cremation  of  the  dead,  and  similar  considerations  have  served  only  to 
inspire  exaggerated  feelings  of  alarm.  As  reflecting  a  laudable  degree 
of  interest  in  medicopublic  affairs,  these  features  are  worthy  of  serious 
consideration,  if  not  of  commendation.  It  appears,  however,  that  the 
promulgation  of  such  opinions  at  this  time  is  not  warranted  by  demon- 
strable etiologic  facts,  and  serves  to  impart  distorted  ideas,  thus  adding 
to  a  somewhat  intolerant  public  sentiment.  While  all  immotlerate 
statements  tending  to  inspire  alarm  must  be  avoided,  enthusiastic  sup- 
port should  be  accorded  to  health  authorities  along  the  lines  of  pre- 
ventive medicine.  Ration.nl  measures  for  the  restriction  of  consumptinn 
should  be  rigicUy  enforced  iiic\crv  Stale.  While  the  buiden  nf  the  ron- 
sumptive  must  not  be  made  hanlei-  to  bear  by  reason  of  erioneons  pojiu- 
lar  impressions,  it  is  apparent  that  the  .safety  of  the  puldic  nui.^t  be 
exalted  above  the  pride  and  sensitiveness  of  individuals.  A  judicious 
and  intelligent  consideration  of  the  rights  of  each  enforces  a  conviction 
as  to  the  wisdom  of  compulsory  municipal  control  and  the  elaboration 
of  a  systematic  campaign  of  popular  education. 

In  addition  to  the  communicability  and  preventability  of  consump- 
tion, the  State  must  needs  take  cognizance  of  its  curabilitji.  The  very 
fact  that  the  disease  so  often  offers  a  possibility  of  cure,  by  which  is 
meant  a  restoration  of  active  usefulness,  emphasizes  the  direct  obligation 
to  make  suitable  provision  for  the  care  and  maintenance  of  those  unfor- 
tunates who  are  incapable  of  self-support.  Substantial  aid  from  this 
source  will  result  in  the  saving  of  life  and  health,  with  an  enormous 
alleviation  of  suffering.  The  duty  of  society  relates  but  little  more  to 
the  preservation  of  communities  than  to  provision  for  the  comfort  and 
welfare  of  her  invalid  class,  who,  prior  to  their  misfortune,  contributed 
so  largely  to  the  prosperity  of  the  State.  By  this  means  there  is  afforded 
a  supervisory  control  of  those  unable  in  their  ordinary  environment  to 
observe  sanitary  precautions  and  who  become,  with  advancing  infection, 
a  distinct  element  of  danger. 

Practical  consideration  for  the  indigent  pulmonary  invalid  is  also 
demanded  of  society  upon  economic  grounds.     With  proper  assistance 


564  PROPHVLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

the  consumptive  is  prevented  from  becoming  permanently  dependent 
upon  others  and  often  is  enabled  to  resume  the  role  of  bread-winner  for 
the  family.  In  like  manner  the  State  is  permitted  to  add  substantially 
to  its  resources  by  preserving  one  of  its  most  valuable  commodities — • 
the  earning  power  of  labor.  If  it  is  deemed  obligator}-  to  provide 
institutions  for  the  non-consumptive  poor,  frequently  reduced  to  pov- 
erty through  their  own  responsibility  as  a  result  of  shiftlessness,  dis- 
sipation, or  inherited  perversion,  who  are  destined  never  to  regain  social 
cast  or  citizenship,  it  would  appear  imperative  to  assist  those  who  have 
suffered  ill  health  through  unnecessary  exposure  for  which  society  is  to 
some  extent  responsible. 

The  duty  of  the  State  to  provide  assistance  for  unfortunate  but 
worthy  consumptives  is  further  emphasized  by  the  fact  that  a  large 
majority  of  such  patients  are  victims  of  delayed  or  erroneous  diagnosis. 
While  this  reflects  directly  upon  the  family  physician,  it  is  also  true 
that  society  must  be  held  responsible  for  errors  on  the  part  of  a  pi'O- 
fession  over  which,  in  different  States,  it  assumes  to  exercise  jurisdiction 
and  control.  As  a  general  rule,  consumption  may  be  regarded  as  a 
curable  disease  onlj'  with  reference  to  eajiy  cases.  Failure  to  appreciate 
fully  the  significance  of  rational  symptoms,  or  to  recognize  and  interpret 
accurately  the  physical  signs  of  incipient  stages,  has  occasioned  an  enor- 
mous annual  sacrifice  of  human  lives,  to  say  nothing  of  the  suffering 
incident  to  prolonged  illness.  The  actual  responsibility  and  culpability 
of  the  family  physician  in  these  cases  is  accentuated  by  the  undeniable 
truth  that  such  disastrous  results  are  often  entirely  without  extenuation. 
In  addition  to  the  grievous  results  of  mistaken  diagnosis  at  the  hands 
of  reputable  practitioners,  other  abuses  of  a  still  more  flagrant  nature 
are  frequently  heaped  upon  the  unfortunate  victim  of  consumption. 
Society,  which  sometimes  encompasses  the  regular  and  legitimate  prac- 
tice of  medicine  with  embarrassing  restrictions,  yet  permits  the  unsus- 
pecting invalid  to  become  the  non-defensive  prey  of  ignorant  and 
unscrupulous  charlatans.  While  many  forms  of  quackery  have  been 
overlooked  and  the  advertisement  and  sale  of  patent  medicines  contain- 
ing alcohol  and  various  narcotics  have  been  permitted,  the  State,  by 
virtue  of  its  failure  to  enact  repressive  legislation  or  to  enforce  existing 
laws,  has  become  indirectly  responsible  for  the  lack  of  public  health. 

From  the  foregoing  considerations  it  is  apparent  that  effective  means 
should  be  employed  to  satisfy  the  respective  claims  of  society  and  her 
invalid  class.  The  conduction  of  an  eclucational  propaganda  to  be  pecu- 
liarly effective  must  emanate  from  some  recognized  responsible  source 
and  be  attended  by  a  cooperation  of  all  organizations  interested  in 
public  health.  It  is  essential  that  a  concerted  campaign  should  be  out- 
lined, under  federal  authority,  or  be  conducted  by  a  parent  national 
organization,  exercising  a  dominating  control  over  the  work  done  in  the 
individual  States.  The  establishment  of  a  national  bureau  of  public 
health,  endowed  with  supervisor}-  authority  over  all  State  and  muni- 
cipal health  officers  is  eminently  practicable.  By  this  means  much  may 
be  aciompli^hed  along  the  lines  of  preventive  medicine,  which  at  present 
is  (lilliiwlr  iif  ]ir:tctical  achievement.  The  scope  and  u.sefulness  of  the 
National  \~M.(i:ition  for  the  Prevention  of  Tuberculosis,  as  well  as  cer- 
tain State  ami  municipal  organizations  along  similar  lines,  will  be  later 
discussed. 

Any  concentrated  effort  toward  the  restriction  of  a  social  disease 


RECIPROCAL    RELATIONS    OF    CONSUMPTIVES    AND    SOCIETY  565 

known  to  be  communicable,  preventable,  and  curable  should  be  directed 
to  the  limitation  of  exposure,  the  prevention  oj  infection  in  spite  of  expo- 
sure, and  the  restoration  of  health  through  the  arrest  of  the  tuberculous 
process  after  infection  has  taken  place.  Under  these  three  headings  may- 
be embraced  the  broad  duty  of  the  Commonwealth  in  the  endeavor  to 
preserve  the  public  health. 

Measures  to  prevent  exposure  must  be  aimed  at  the  contagium, 
which  constitutes  the  primary  source  of  the  disease,  i.  e.,  the  tubercle 
bacillus.  Efforts  to  limit  infection  must  be  directed  toward  a  variety 
of  secondary  causes,  which  coinhiiic  tn  so  diminish  the  powers  of  resist- 
ance as  to  create  a  predisposition  on  the  part  of  the  individual.  It  has 
been  explained  that  the  implantation  of  bacilli  sufficient  for  the  pro- 
duction of  clinical  manifestations  is  only  possible,  as  a  rule,  from  pro- 
longed exposure  and  a  certain  receptivity  of  the  soil.  In  the  light  of 
our  modern  kiiowledj^fc'  it  appears  that  an  active  spectacular  campaign 
against  the  siciiinKjIii  u)ii(juitous  agent  of  infection  alone,  is  quite  imprac- 
ticable. The  ]iie\eution  of  consumption,  to  be  really  effective,  must  be 
based  upon  other  conceptions  than  the  one  idea  of  exposure  after  the 
manner  of  leprosy  or  a  few  intensely  contagious  diseases.  For  the  legiti- 
mate control  of  tuberculosis  there  should  not  be  contemplated  a  "  cru- 
sade" against  the  offending  microbe  under  the  delusion  that  a  war  of 
extermination  will  suffice  to  obliterate  the  disease.  Practical  results 
are  to  be  acquired  from  a  rational  insistent  demand  for  the  betterment 
of  all  conditions  possfK.^iiiij  (linloijir  significance.  Much  has  been  printed 
of  late  as  to  the  pununouni  necessity  of  the  destruction  of  the  bacillus 
in  order  to  forestall  the  "  uniuliilation  of  consumption."  Essayists  have 
waxed  eloquent  in  their  predictions  I'onccniiui;  the  "  wiphii,'  out"  of  the 
disease,  its  "stamping  out"  or  "blot  i  iiii;(iiit .  "  mid  "its  c  indication  from 
the  face  of  the  earth."  In  this  coniicrtion  it  is  pen  iiii-iii  to  suggest  that 
the  ultimate  effacement  of  tuberculosis  can  tal^e  place  only  as  a  result 
of  a  broadly  conceived  and  well-sustained  movement,  which  takes  cogni- 
zance of  each  factor  capable  of  influencing  the  spread  of  the  disease. 
The  incidental  limitation  of  its  ravages  through  the  extension  of  sub- 
stantial aid  to  a  class  of  citizens  in  every  way  worthy  of  practical 
assistance  constitutes  an  important  feature  of  a  campaign,  to  be  con- 
ducted through  effectiveness  of  organization  and  thoroughness  of  prepa- 
ration. Among  other  features  there  is  indicated  a  comprehensive  and 
perfected  system  of  public  philanthropy,  through  which  means  enduring 
economic  results  may  be  secured. 

The  prophylactic  and  humanitarian  efforts  of  society  with  reference 
to  consumption  should  embrace  the  following  methods  of  procedure. 

1.  Compulsory  notification  and  registration  of  all  cases  of  pulmonary 
tuberculosis. 

2.  A  personally  conducted  supervision  of  the  consumptive  and  his 
environment,  including  an  elaborate  system  of  education. 

3.  The  extension  of  material  aid,  when  necessary,  according  to  the 
varying  needs  and  requirements  of  differing  classes. 

4.  The  dissemination,  to  the  general  public,  through  the  medium  of 
various  channels,  of  authentic  official  information  regarding  the  preven- 
tion of  consumption. 

5.  The  administrative  control  of  all  important  factors  entering  into 
the  problem  of  etiology  and  prophylaxis. 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


CHAPTER  LXXXIII 
COMPULSORY  NOTIFICATION  AND  REGISTRATION 

It  is  necessarj-  to  know  precisely  where  and  when  the  disease  exists 
in  order  to  inaugurate  any  systematic  and  direct  supervision,  without 
which  an  effective  administrative  control  of  tuberculosis  is  utterly  impos- 
sible. Some  form  of  registration,  therefore,  is  absolutely  essential  as  an 
important  preliminary  to  successful  municipal  efforts  toward  prevention. 
A  considerable  difference  of  opinion  has  been  entertained  regarding  the 
relative  merits  of  voluntary  and  enforced  notification,  objection  having 
been  made  to  registration  without  the  consent  of  the  patient  or  family. 
In  view  of  the  comparatively  slight  difBculty  experienced  in  maintaining 
strict  privacy,  opposition  has  of  late  diminished  very  perceptibly. 

It  is  quite  apparent  that  the  effectiveness  of  notification  as  a  factor 
in  prophylaxis  is  dependent  altogether  upon  the  completeness  of  its 
execution.  Voluntary  reports,  though  inspired  in  individual  instances 
through  highly  conscientious  motives,  are  nevertheless  sadly  incomplete 
in  their  general  application.  Upon  the  other  hand,  the  value  of  com- 
pulsory notification  depends  not  upon  the  enactment  of  orcUnances  to 
this  effect,  but  upon  the  existence  of  such  professional  and  popular 
sentiment  as  will  demand  its  rigid  enforcement.  The  logical  solution  of 
this  problem  is,  therefore,  through  the  edxwation  of  the  profession  and  the 
public,  before  attempting  administrative  measures  which  may  appear 
unnecessarily  drastic. 

Even  faithful  compliance,  whether  voluntary-  or  compulsory,  with 
regulations  governing  notification  and  registration,  is  of  no  practical 
avail  unless  followed  by  further  organized  efforts  on  the  part  of  the 
municipality  toward  the  restriction  of  the  disease.  It  is  useless,  there- 
fore, to  advocate  notification  in  large  cities  unless  the  health  authorities 
are  in  a  po.sition  to  carry  the  campaign  of  education  and  supervision 
into  the  very  homes  of  those  afl^icted.  This  involves  no  publicity  and 
implies  no  such  extreme  measures  as  the  placarding  of  houses,  isolation, 
or  personal  humiliation.  There  need  be  contemplated  no  interference 
with  personal  rights,  family  ties,  social  conditions,  or  bu.siness  pursuits, 
unless  rendered  necessary  bj'  repeated  and  intentional  infractions  of  pre- 
scribed regulations.  No  hardship  whatever  is  inflicted  upon  the  con- 
sumptive or  family,  but  opportunity  is  offered  to  receive  instructions 
from  a  definitely  responsible  source.  This  inures  greatly  to  the  benefit 
of  the  invnlifl  and  those  about  him,  while  society  profits  from  the  addi- 
tional tatilities  afforded  for  the  maintenance  of  rational  supervision. 

Then'  sliniild  lie  impartefl  competent  instruction  as  to  the  nature  of 
the  disease,  and  as  to  the  dangers  of  contagion  in  the  absence  of  precau- 
tionary measures.  No  less  important  than  the  inspection  of  apartments, 
or  disinfection  of  rooms  and  clothing,  is  the  adoption  of  therapeutic 
efforts,  the  reafssiirance  of  others  when  necessary,  craminations  of 
members  of  the  famih/,  investigations  of  predisposinc/  conditions,  and 
free  reports  of  sputum  analy.ses.  In  fact,  almost  the  entire  system  of 
municipal  control  subsequently  to  be  elaborated  is  contingent  upon 
the  knowledge  of  the  existing  centers  of  possible  infection.  Assuredly 
such  information  cannot  be  obtained  solely  from  the  mortality  records, 


COMPULSORY    NOTIFICATION    AND    REGISTRATION  5b/ 

but  rather  from  the  willing  cooperation  of  physicians  in  reporting  all 
cases  of  existing  disease.  The  element  of  compulsion,  though  not 
primarily  essential  and  of  less  value  than  an  awakened  public  sentiment, 
is  yet  demanded  in  order  that  means  may  be  provided  for  the  detection 
and  punishment  of  offenders.  This  is  rendered  entirely  practicable  by 
a  comparison  of  the  death  certificates  with  the  previous  registration 
of  tuberculosis.  Thus  a  check  is  permitted  upon  the  honesty  and 
accuracy  of  individual  reports. 

It  does  not  appear  that  valid  objection  could  be  made  in  any  com- 
munity against  the  institution  of  measures  of  this  kind  calculated  to 
conserve  the  interests  of  the  invalid  as  well  as  the  public.  Yet  in  some 
localities  even  in  spite  of  municipal  ordinances  governing  notification, 
the  law  "is  more  honored  in  the  breach  than  the  observance."  With 
the  increasing  enlightenment  of  the  people  there  is  but  slight  excuse 
for  further  resistance  to  the  policy  of  registering  living  cases  of  con- 
sumption as  well  as  the  dead.  It  is  incomprehensible  that  civic  pride 
can  tolerate  the  ostrich-like  habit  of  hiding  the  head  to  real  facts  con- 
cerning the  existence  of  consumption  and  suffer  delusions  of  terminology 
to  increase  the  actual  dangers  of  the  disease. 

It  is  significant  that  the  most  gratifying  results  in  the  prevention  of 
tuberculosis  have  been  secured  wherever  the  laws  pertaining  to  notifica- 
tion have  been  strictly  enforced.  New  York  has  set  an  example  to  the 
entire  world,  not  only  in  the  early  adoption  of  registration  laws,  but  in 
a  demonstration  of  the  value  and  practicability  of  their  compulsory 
observance.  In  1893  notification  became  partly  voluntary  and  partly 
obligatory  in  that  city.  Only  in  public  institutions  was  this  com- 
pulsory, but  a  strong  effort  was  made  to  create  a  professional  senti- 
ment favoring  voluntary  reports  to  the  Department  of  Health.  In 
spite  of  somewhat  strenuous  opposition,  the  spirit  of  administrative 
control  after  a  few  years  became  more  firmly  established.  Through  the 
substantial  influence  of  a  medical  advisory  board,  comprising  some  of 
the  most  eminent  physicians  in  New  York,  there  were  inculcated  grad- 
ually more  sensible  and  progressive  views  among  the  profession  and 
public.  In  this  manner  greater  confidence  was  inspired  as  to  the 
correctness  of  the  advanced  position  assumed  by  the  Department  of 
Health  under  the  aggressive  leadership  of  Dr.  Biggs.  During  the 
first  year  4000  cases  of  consumption  were  reported  and  500  specimens 
of  sputum  submitted  for  bacteriologic  examination.  In  1897  an  amend- 
ment to  the  Sanitary  Code  was  adopted,  requiring  the  reporting  of  all 
cases.  More  than  25,000  cases  of  tulierculosis  are  now  reported  annually, 
and  an  approximately  equal  number  of  free  examinations  of  sputum 
are  made.  While  a  certain  small  propoi'tion  of  consumptives  must 
remain  unregistered,  it  is  probable  that  more  than  three-fourths  of  all 
cases  are  recorded  in  the  Health  Department  and  subjected  to  the 
advantages  of  supervisory  control.  The  practical  results  obtained  in 
the  diminution  of  coiisiiiriittinn  in  .\cw  ^■<)^k  ;ii-c  ]>:irticul:uly  enlighten- 
ing. In  no  other  cit)-  in  the  wdild  has  iliciv  lakcii  piaic  any  reduction 
of  the  death-rate  fioin  lulx'iculnsis  at  .all  cnniiiara.Me  to  that  achieved 
in  our  American  nicti(i|i(ilis,  in  s]jite  of  the  density  of  her  population  in 
tenement  districts  and  tlir  diivst  poverty  among  a  large  class  of  people 
of  foreign  birth.  The  fall  in  tlie  mortality  rate  during  the  past  twenty 
years  is  estimated  at  about  40  per  cent.,  inclusive  of  all  cases  of  tuber- 
culosis.    No  more  striking  commentary  can  be  afforded  as  to  the  benefi- 


568  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

cent  and  practical  results  capable  of  attainment  in  the  supervision  of 
a  disease  to  a  large  extent  preventable. 

In  England  the  Government,  for  the  purposes  of  observation  and 
educational  review,  has  permitted  the  enforcement  of  compulsory 
notification  for  a  limited  time  in  a  single  large  city  (Sheffield).  Scur- 
field.  Medical  Health  Officer  to  the  City  of  Sheffield,  reports  that  the 
Compulsory  Notification  Act  has  been  in  operation  since  November  1, 
1003,  without  any  organized  opposition  on  the  part  of  the  public  or 
the  profession.  Voluntary  notification  had  been  in  vogue  during  the 
preceding  four  years.  The  general  attitude  in  England  must  be  regarded 
at  present  as  one  of  reserve  and  conservatism.  This  is  perhaps 
occasioned  in  part  by  the  fact  that  many  of  the  most  eminent  medical 
authorities  have  not  been  in  strict  accord  concerning  the  expediency 
of  obligatory  notification.  Sir  Richard  Thorne,  the  Medical  Adviser 
to  the  Local  Government  Board  of  Great  Britain,  in  his  lecture  upon 
the  Administrative  Control  of  Tuberculosis  one  year  after  the  adoption 
of  compulsory  notification  in  New  York  city,  definitely  opposed  such 
a  procedure  in  England,  regarding  it  to  be  completely  unjustifiable. 

In  Scotland,  where  approximately  10,000  people  die  annually  from 
some  form  of  tuberculosis,  a  more  determined  effort  toward  adminis- 
trative control  has  been  established.  During  the  thirty  years  from 
1871  to  1901,  the  death-rate  from  phthisis,  according  to  Bramwell,  has 
been  reduced  from  278  to  153  per  100,000.  In  the  latter  part  of  1906, 
compulsory  notification  was  unanimously  adopted  in  Glasgow,  a  system 
of  voluntary  notification  having  been  in  operation  during  the  preceding 
six  years.  In  other  cities  a  similar  voluntary  sj'stem  is  now  in  vogue, 
but  through  the  noteworthy  efforts  of  Bramwell,  McKenzie,  Phillips, 
and  Dittman,  this  is  being  more  generally  regarded  as  an  unfortunate 
compromise,  if  not  a  vicious  makeshift. 

In  Ireland,  according  to  the  reports  of  Sir  John  W.  Moore  and 
Edward  J.  McWeeney,  the  magnitude  of  the  tuberculosis  problem  is 
illustrated  by  the  fact  that  the  death-rate  has  recently  reached  the 
maximum  of  2.9  per  1000  of  the  population,  representing  the  deaths  of 
12,694  per.sons  during  the  year.  Only  in  the  years  1880,  1897,  1898, 
and  1900  has  such  a  high  mortality  rate  been  previously  attained. 
The  death-rate  in  England  is  reported  to  have  fallen,  since  1864,  from 
3.3  per  1000  to  1.7;  in  Scotland,  from  3.6  per  1000  to  2.1,  and  yet  in 
Ireland  to  have  risen  from  2.4  per  1000  in  1864  to  2.9  in  1904.  That 
the  Irish  jipople  are  awakening  to  the  enormity  of  the  danger  is  evidenced 
by  the  f.ict  tlmt  in  1906,  at  a  meeting  of  the  Dublin  Branch  of  the 
Natioii.il  A>s(iriation  for  the  Prevention  of  Consumption,  a  resolution 
was  u(l(i|)ted  providing  for  the  adoption  of  a  system  of  compulsory 
notification. 

In  Denmark,  according  to  Vilhelm  Maar,  20,000  people  out  of  a  total 
of  2,500,000  inhabitants  are  at  present  afflicted  with  tuberculosis,  and 
approximately  8000  new  cases  are  developing  annually.  In  compliance 
with  the  suggestions  embodied  in  the  report  of  the  Parliamentary 
Commission  appointed  in  November,  1901,  to  investigate  conditions 
and  propose  remedial  measures,  all  physicians  are  compelled  to  report 
cases  of  existing  tuberculosis  coming  under  their  observation  as  well 
as  the  deaths. 

In  Australia,  which  possesses  a  dry  sunny  climate  with  a  compara- 
tively small  population  exhibiting  but  little  poverty,  the  death-rate 


COMPULSORY    NOTIFICATION    AND    REGISTRATION  569 

from  tuberculosis  is  reported  by  Armstrong  as  29  per  cent,  less  than  in 
England  in  1904.  The  mortality  rate  has  become  progressively  reduced 
since  1885.  Compulsory  notification  has  been  in  force  in  parts  of  Aus- 
tralia smce  1898.  Neglect  to  comply  with  notification  laws  is  subject 
to  heavy  penalty.  Gratifying  results  have  been  secured  in  Adelaide, 
Melbourne,  and  Sydney. 

In  Roumania,  ilitulescu  reports  that  the  death-rate  from  tuberculosis 
in  the  large  cities  is  3.6  per  1000  people,  the  rate  in  Bucharest  being 
particularly  high.  Since  1901  effective  efforts  have  been  instituted  to 
introduce  compulsory  notification,  work  along  these  lines  being  accorded 
active  support  by  the  profession  and  public. 

Great  interest  in  the  campaign  against  tuberculosis  is  manifested 
in  Norway,  Holland,  Switzerland,  and  Belgium.  Compulsory  notifica- 
tion is  admitted  to  be  a  decided  success  in  Norway,  where  it  has  been 
carried  out  since  1901,  and  is  earnestly  advocated  by  the  leaders  of  the 
profession  in  other  countries.  Holmlxic.  nf  (  luistiana,  reports  that 
obligatory  notification  no  longer  meets  with  icsistance,  that  early 
exaggerated  notions  as  to  the  fear  of  infecliun  have  subsided,  and  that 
administrative  control  is  meeting  with  growing  favor  on  account  of  the 
increasing  enlightenment  of  the  people.  Dr.  Carriere,  of  Berne,  reports 
a  progressive  diminution  in  the  mortality  rate  of  pulmonary  tuberculosis 
since  1883,  despite  an  increase  in  the  total  mortality  from  other  tubercu- 
lous affections. 

In  Germany  it  is  estimated  from  the  official  data  furnished  by  the 
Imperial  Health  Office  that  from  110,000  to  120,000  people  die  annually 
of  consumption.  In  nearly  all  cities  the  statistics  show  a  gratifying 
diminution  in  the  mortality  rate  of  tuberculosis  of  approximately  40  per 
cent,  during  the  past  thirty  years.  Many  municipalities  have  adopted 
regulations  enforcing  obligatory  notification  and  registration.  Com- 
pulsory notification,  according  to  Glasenapp,  President  of  Police,  Rix- 
dorf ,  is  soon  to  be  introduced  in  that  city  for  all  cases  of  open  pulmonary 
or  laryngeal  tuberculosis.  The  unfortunate  results  of  the  present  lack 
of  compulsory  notification  are  greatly  minimized,  however,  by  the  work 
of  the  inquiry  bureaus  and  tuberculous  dispensaries.  Kayserling,  Secre- 
tary General  of  the  Central  Committee  for  these  oi-ganizations  in  Berlin 
and  suburhs,  reports  that  detailed  notification  is  obligatory  upon  the 
nurses  connected  with  the  service,  and  that  effective  measures  of  pre- 
vention and  supervision  are  immediately  instituted  by  the  inquiry 
stations.  In  France  the  principle  of  compulsory  notification  at  first  met 
with  considerable  opposition.  In  1899  the  Acailemy  of  Medicine  in  Paris 
appointed  a  special  commission  to  suljmit  propositions  regarding  the 
administrative  control  of  tuberculosis.  Compulsory  notification  was 
resisted  strongly  at  that  time  as  being  uncalled  for  and  distinctly 
objectionable. 

In  recent  years  a  vast  amount  of  good  has  been  accomplished  by  the 
Permanent  Committee  for  the  Prevention  of  Tuberculosis  in  France, 
pubhc  interest  having  been  awakened  with  reference  to  all  important 
features  of  prophylaxis. 

While  many  American  cities  have  emulated  the  example  of  New 
York  in  adopting  regulations  requiring  reports  of  tuberculosis  to  health 
authorities,  but  comparatively  few  compel  their  actual  enforcement. 
In  Philadelphia  notification  was  recommended  by  the  County  Medical 
Society  in  1893,  but  failed  of  inauguration  until  1905.     In  Boston  com- 


570 


PROPHYLAXIS,    GENERAL    AND    SPECIFIf    TREATMENT 


pulsory  registration  has  been  in  force  since  1900.  Of  the  86  largest 
cities  of  the  United  States,  according  to  a  report  made  by  Wm.  H. 
Baldwin  and  other  members  of  a  committee  appointed  by  the  National 
Association  for  the  Prevention  of  Consumption,  57  had  enacted  laws  by 

the  early  part  of  1906,  pertaining  to  compulsory  registration.  Of  these 

57,  nearly  one-fifth  passed  their  ordinances  during  1905,  as  will  be  seen 
by  the  following  table  presented  by  the  committee: 

_                                                                          r,.„„ T  .„,  Population,  Forms  to  be 

City.                                                                    Date  of  Law.  jg^j  Reported. 

New  York  City Jan.      18,1897  3,437,202  All 

Camden,  N.  J Dec.     27,  1897  73,935  All 

Cincinnati,  O Aug.     19.  1898  325,902  Not  stated 

Elizabeth,  N.J March    6,  1899  52,130  Not  stated 

Boston,  Mass May       1,  1900  560,892  Pulmonary 

Buffalo,  N.Y 1900  352,387  Not  stated 

Rochester,  N.Y 1900  162,608  Not  stated 

Trenton,  N.J Jan.        8,  1901  73,307  Pulmonary 

Bridgeport ,  Conn April    23,  1902  70,996  Pulmonary 

Lowell.  Mass Sept.           1902  94,969  Pulmonary 

Worcester,  Mass Oct.        6,1902  118,421  Pulmonary 

Louisville,  Ky Oct.            1902  204,731  Not  stated 

Atlanta,  Ga Oct.            1902  89,872  Not  stated 

Oakland,  Cal 1902  66,960  Pulmonary 

Providence,  R.  I Jan.      15,1903  175,597  All 

Hartford,  Conn March    4,  1903  79,850  All 

Cambridge,  Mass March  11,  1903  91,886  Pulmonary 

Omaha,  Neb June     30,  1903  102,555  Not  staled 

San  Francisco,  Cal Oct.     27,1903  342,782  All 

Los  Angeles,  Cal Oct.            1903  1 02,479  Not  stated 

Memphis,  Tenn 1903  102,320  Not  stated 

St.  Paul,  Minn Jan.            1904  163,065  All 

Minneapolis,  Minn Aug.     26,1904  202,718  All 

Reading,  Pa Sept.      1,  1904  78,961  All 

Somerville,  Mass Oct.        6,  1904  61,643  Pulmonary 

*Des  Moines,  la Oct.     28,  1904  62,139  All 

Springfield,  Mass Nov.       1,  1904  62,059  Not  stated 

Cleveland,  O Feb.       3,1905  381,768  Not  stated 

Youngstown,  O Feb.        6,  1905  44,885  Pulmonary 

Yonkers,  N.  Y Feb.            1905  47,931  Not  stated 

Paterson,  N.  J March    3,  1905  105,171  Pulmonary 

*Salt  Lake  City,  Utah March    9,  1905  53,531  Pulmonary 

Grand  Rapids,  Mich March         1905  87,565  Pulmonary 

St.  Louis,  Mo April      7,  1905  575,238  Pulmonary 

♦Baltimore,  Md April      8,1905  508,957  Pulmonary 

tPhiladelpliia,  Pa April    27,1905  1,293,697  Pulmonary 

New  Haven,  Conn April          1905  108,027  Not  stated 

♦Milwaukee,  Wis May     15,  1905  285,315  All 

Fall  River,  Mass June     13,  1905  104,863  Pulmonary 

Waterbury,  Conn Sept.      5,  1905  45,859  All 

tPittsburgh,  Pa Sept.    10,1905  321,616  All 

New  Bedford,  Mas.s Nov.      8,  1905  62,442  Not  stated 

Columbus,  Ohio 1905  125,560  Not  stated 

Erie,  Pa Jan.        1,1906  52,733  Not  stated 

Chicago,  111 Jan.        1,  1906  1,698,575  All 

Liiwicncf,  Mass Feb.     19,1906  62,559  All 

r.  ..Ill,  111 Feb.     20,1906  56,100  Not  stated 

U.tinii,  Mich 285,704  Not  stated 

llulyuke,  .Mass 45,712  Not  stated 

Seattle,  Wash 80,671  All 

Wilkes  Barre,  Pa 51,721  Not  stated 

Troy,  N.  Y 60,551  Not  stated 

Indianapolis,  Ind 169.164  Not  stated 

*Stato  law 

fState  law;  enforcement  in  this  city  begun  about  this  time. 


THE    SUPERVISION    AND    EDUCATION    OF    THE    CONSUMPTIVE        571 


The  only  cities  of  over  125,000  population  which  had  not 
ordinances  requiring  notification  were  Chicago,  New  Orleans,  Newark, 
Jersey  City,  Kansas  City,  and  Denver.  It  is  frequently  urged  by  some 
that  compulsory  notification  is  especially  indicated  for  Denver  on 
account  of  the  influx  of  imported  cases,  and  the  possible  development  of 
an  indigenous  disease  seriously  imperiling  the  future  of  the  community. 
While  denying  that  for  such  alleged  reason  an  unusual  necessity 
exists  in  Colorado  for  a  tuberculosis  crusade,  it  is  admitted,  nevertheless, 
that  measures  for  the  restriction  and  control  of  tuberculosis  should  be 
rigidly  enforced  in  Denver  as  elsewhere.  That  such  is  not  the  case  is 
indeed  a  reflection  upon  the  profession,  unextenuated  by  the  existence 
of  favorable  climatic  conditions,  the  absence  of  an  overcrowded  popu- 
lation, or  the  relatively  insignificant  amount  of  poverty.  Irrespective 
of  locality  or  other  inherent  etiologic  factors  there  should  be  observed  in 
all  cities  compulsory  notification  as  preliminary  to  a  campaign  of  edu- 
cation and  supervision.  This  should  embrace  all  ca.ses  of  tuberculosis, 
include  each  change  of  dwelling,  and  become  obligatory  upon  the  attend- 
ing physician,  the  nurse,  the  head  of  the  family,  and  the  owner  of  the 
house. 


CHAPTER   LXXXIV 

THE  SUPERVISION  AND  EDUCATION  OF  THE 
CONSUMPTIVE 

The  pulmonary  invalid,  in  the  absence  of  certain  precautions  relative 
to  daily  habits,  is  a  direct  menace  to  the  family  and  the  public,  but 
strict  conformity  to  prescribed  instructions  entirely  removes  all  elements 
of  danger.  Upon  these  premises  two  conclusions  are  obvious.  First, 
that  society  has  the  right  to  demand  of  the  consumptive  the  most  rigid 
observance  of  sanitary  rules,  and,  secondly,  that  the  victim  of  tuberculo- 
sis is  entitled  to  receive  from  the  health  authorities  systematic  instruc- 
tion with  reference  to  the  arrest  as  well  as  the  control  of  the  disease. 
The  burden  of  action  thus  lies  with  the  public  in  the  education  of  the 
consumptive  preparatory  to  any  successful  scheme  of  supervision.  To 
this  end  public  eff'ort  toward  the  restriction  of  the  disease  should  con- 
sist primarily  of  such  assistance  as  will  secure  a  hearty  recognition  of 
reciprocal  obligations.  The  methods  to  be  employed  in  undertaking 
the  education  of  the  invalid  are  various.  Certain  well-defined  groups 
of  consumptives  are  recognized  to  whom  are  indicated  separate  and 
widely  differing  means  of  imparting  knowledge. 

In  many  instances  the  attending  physician  represents  one  of  the  most 
important  channels  Ijy  which  information  may  be  conveyed  with  the 
greatest  likelihood  of  enlisting  active  cooperation.  Unfortunately,  the 
practical  effectiveness  of  this  method  may  be  limited  in  its  general  appli- 
cability by  the  negligence  of  the  physician.  Too  often  the  general  prac- 
titioner either  utterly  fails  to  appreciate  his  responsibility  in  the  mat- 
ter, or  neglects  to  impart  detailed  instruction  solely  on  account  of  the 
time  and  trouble  involved.  In  other  cases  the  physician,  although  per- 
haps earnest  and  conscientious,  may  not  be  sufficiently  informed  to  train 


572  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

the  patient  in  a  proper  manner.  In  many  instances,  however,  according 
to  the  discretion  of  the  health  authorities,  the  personal  instruction  of 
the  consumptive  may  be  delegated  to  the  phj^sician  in  charge,  but  this, 
under  no  circumstances,  should  prevent  the  supplementary  distribution 
of  educational  literature,  in  order  to  insure  accuracy  and  thoroughness 
of  observed  precautions. 

Among  the  more  intelligent  classes  carefully  prepared  circular  infor- 
mation, portraying  in  detail  the  necessary  preventive  measures,  often 
suffices  to  impart  to  the  invalid  an  adequate  conception  of  individual 
responsibilities.  Grateful  and  appreciative  readers  of  such  literature  are 
not  always  found  among  the  masses,  particularly  the  wage-earners,  who 
are  often  indifferent  to  their  surroundings  and  careless  in  their  habits.  For 
these,  educational  leaflets  of  a  more  emphatic  nature  are  demanded,  and 
their  contents  should  be  adapted  to  the  peculiar  requirements  of  such  a 
class.  Such  circulars  of  information  should,  above  all,  be  clear,  brief, 
concise,  of  simple  phraseology,  in  effect  more  or  less  mandatory,  without 
attempt  at  unnecessary  explanation,  and  printed  in  various  languages. 

The  work  of  responsible  instruction  must  develop  in  the  main  upon 
duly  authorized  and  specially  trained  assistants,  working  under  the  sanc- 
tion either  of  the  Health  Department  or  of  various  charity  organizations. 
Through  the  influence  of  personal  contact  and  force  of  example,  educated 
women  serving  either  as  visiting  nurses  or  sanitary  inspectresses,  are 
enabled  to  inspire  immediate  confidence  and  secure  intelligent  cooper- 
ation. Thus  the  precautionary  rules  left  for  perusal  are  more  likely  to 
be  understood  and  obeyed.  PeriocUc  visits,  with  systematic  reports  to 
higher  authorities,  result  in  the  preservation  of  valuable  records,  through 
which  means  administrative  control  may  become  more  effective  and 
the  official  mind,  if  occasion  requires,  awakened  to  the  necessity  of 
coercive  action. 

Other  means  for  the  education  of  the  consumptive  are  afforded 
through  the  medium  of  tuberculosis  classes,  free  dispensaries,  sanatoria, 
and  the  various  methods  of  enlightening  the  general  public,  to  all  of 
which  consideration  will  be  given  in  the  proper  place. 

Tuberculosis  is  essentially  a  house  disease,  however,  and  it  is  in  the 
hojne  that  the  vast  majority  of  pulmonary  invalids  must  receive  their 
instruction  and  become  subject  to  supervision.  By  far  the  most  impor- 
tant feature  of  prophylaxis  relates  to  the  disposal  of  the  sputum  in  the 
sick-room,  and  it  is  to  this  phase  of  the  subject  that  especial  attention 
must  be  directed. 

It  is  essential  that  scrupulous  care  be  taken  to  avoid  contamination 
of  clothing,  bedding,  furniture,  rugs,  floor,  hands,  lips,  beard,  or  any 
other  portion  of  the  body  with  tubercle  bacilli.  In  the  act  of  coughing 
tiny  invisible  droplets  of  infective  material  may  lie  forcefully  distrili- 
uted  in  all  directions.  For  this  reason  it  is  important  that  the  spray 
be  arrested  by  some  suitable  medium  held  before  the  mouth  at  such  a 
time.  For  this  purpo.se  paper  napkins  or  pieces  of  gauze  or  old  cloth 
are  usually  available,  and  should  be  immediately  burned  or  deposited 
in  a  paper  bag,  paraffined  envelop,  reticule,  or  similar  receptacle  made 
of  oiled  silk  or  rubber.  It  is  undesirable  to  make  use  of  the  handker- 
chief in  endeavoring  to  prevent  a  possible  dissemination  of  bacilli,  but 
such  practice  is,  of  course,  less  objectionable  and  filthy  than  the  habit 
of  utilizing  it  at  the  time  of  expectoration.  If  the  patient  holds  the 
handkerchief  before  the  mouth  when  coughing,  this  should  be  folded 


THE    SUPERVISION    AND    EDUCATION    OF    THE    CONSUMPTIVE        573 

at  once  and  set  aside  until  cleansed  in  the  manner  to  be  described 
for  all  linen.  In  the  absence  of  suitable  material  upon  which  to  gather 
the  tlroplet  emanations  from  the  mouth  while  coughing,  the  patient 
should  be  instructed  to  hold  the  hand  before  the  lips  and  wash  it  at 
once.  The  lips  should  be  carefully  wiped  with  paper  napkins  or  gauze, 
although  in  some  cases  preference  is  given  to  washing  with  a  mOd 
disinfecting  solution.  In  this  event  the  advantage  accrues  not  so  much 
from  the  nature  of  the  .solution,  as  from  the  thoroughness  of  cleansing. 
No  handkerchief,  gauze,  or  cloth  should  be  used  more  than  once  for 
wiping  the  lips. 

As  a  rule,  the  consumptive  should  be  advised  to  dispense  with  his 
beard,  especially  if  at  all  luxuriant.  Nothing  is  more  unsightly  or 
unclean  than  an  overhanging  growth  upon  the  upper  lip  of  pulmonar}'- 
invalids,  unless  it  is  the  time-honored  chin-whisker  of  our  countrymen 
upon  which  may  adhere  particles  of  bacilli-laden  sputum.  If  objection 
be  made  to  the  removal  of  the  beard,  it  at  least  should  be  cropped  very 
closely. 

A  proper  receptacle  for  the  sputum  is  of  the  utmost  importance. 
It  is  essential  that  the  expectoration  should  not  be  permitted  to  dry 
exposed  to  the  air  of  the  room,  nor  to  soil  liy  accident  any  article  for 
which  it  was  not  intended.  It  should  be  deposited,  without  going 
astray,  in  earthen  cups  partly  filled  with  water,  in  paper  spit-cups,  or 
upon  pieces  of  gauze.  Old-fashioned  cuspidors  upon  the  floor  are  an 
abomination  not  to  be  tolerated.  In  all  instances  the  patient  should 
deposit  the  s])utuni  with  the  cup  or  other  receptacle  held  closely  to  the 
mouth,  in  oi'dci'  to  avoid  scattering  the  agents  of  infection.  Earthen 
cups  used  for  tliis  inirpo.se  should  be  cylindric  in  shape  and  provided 
with  a  cover.  It  is  important  that  some  means  be  taken  to  conceal 
the  unsightly  expectoration  and  prevent  the  entrance  of  flies,  thus 
avoiding  consequent  distribution  of  bacilli  to  articles  of  food,  as  has 
been  described.  Under  no  circumstances  should  there  be  used  hand 
cuspidors  with  an  inclined  ujjper  surface  terminating  in  a  small  aper- 
ture at  the  center,  as  it  is  inevitable  that  particles  of  adherent  sputum 
will  become  dried  upon  the  presenting  upper  portion.  Caution  should 
be  exercised  to  ]irevent  the  retention  of  sputum  in  a  similar  manner 
upon  the  sides  or  edges  of  earthen  cylindric  cups.  If  paper  spit-cups 
are  used,  they  should  be  destroyed  by  fire,  and  if  these  are  contained 
within  a  square  tin  box,  the  latter  should  be  boiled  daily.  If  pieces 
of  cheese-cloth  or  gauze  are  emj^loyed,  they  should  be  folded  immedi- 
ately after  expectoration,  and  deposited  temporarily  in  a  proper  recep- 
tacle, as  has  been  explained,  and  subsequently  burned.  If  an  ordinary 
earthen  cup  is  used  as  a  receptacle  for  the  sputum,  it  is  important  that 
it  should  have  a  handle  and  be  partly  filled  with  water.  It  is  unneces- 
sary to  employ  disinfectants,  provided  proper  attention  is  given  to 
emptying  and  refilling  the  cup  at  frequent  intervals.  If  a  receptacle  of 
this  sort  is  used,  the  primary  essential  is  that  the  sputum  should  be 
kept  moist  and  covered.  In  cities  with  modern  sewerage  facilities  the 
cup  may  be  emptied  into  the  water-closet.  In  other  cases  the  sputum 
should  either  be  boiled  or  exposed  to  a  strong  phenol  solution  for  several 
hours. 

An  elaborate  method  for  the  sterilization  of  tuberculous  sputum  has 
been  described  by  Kirkland  and  Patterson.  The  sputum  is  poured  into  an 
iron  vessel,  which  is  provided  with  a  movable  lid  and  has  at  the  bottom 


574  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

two  steam  jets  which,  in  operation,  give  a  circular  motion  to  the  contents. 
After  the  aputum  has  been  emptied  into  the  iron  receptacle  and  the 
lid  screwed  down,  the  steam  is  introduced  through  the  jets  at  the  bottom 
to  a  pressure  of  fifteen  pounds.  After  the  sputum  has  boiled  for  twenty 
minutes  it  is  allowed  to  cool,  and  is  then  drained  into  the  sewer  by  the 
opening  of  a  valve  at  the  bottom  of  the  sterilizer.  The  sputum-cups 
are  cleaned  in  a  somewhat  similar  manner.  They  are  first  suspended 
by  their  handles  upon  a  series  of  horizontal  brass  tubes,  which  form  the 
essential  feature  of  a  cage  which,  in  turn,  is  lowered  into  the  iron  tank. 
Into  this  are  admitted  water  and  steam,  the  boiling  being  permitted 
for  twenty  minutes.  The  advantages  of  this  method  appear  to  be 
marked  economy  of  time,  greater  safety  in  the  handling  of  the  cups, 
and  more  thoroughness  than  if  washed  by  hand. 

It  is  of  the  utmost  importance  that  proper  provision  be  made  for 
the  cleansing  and  sterilization  of  the  linen.  In  the  later  stages  of 
consumption,  when  the  patient  is  completely  bedridden,  the  danger 
of  soiling  the  linen  with  infected  sputum  becomes  exceedingly  great 
on  account  of  the  physical  exhaustion.  In  many  cases  the  intellect 
is  impaired  more  or  less  and  the  patient  is  totally  unable  to  appreciate 
his  status  as  a  source  of  danger  to  others.  The  responsibilitj-  for  a 
proper  hygiene  of  the  sick-room  then  devolves  entirely  upon  the  atten- 
dant. At  such  a  time  it  is  better  that  the  sputum  should  be  deposited 
upon  pieces  of  cheese-cloth  or  gauze,  rather  than  in  sputum-cups,  as 
these  are  often  upset  if  permitted  in  the  hands  of  the  patient.  The 
paramount  consideration  relates  to  the  observance  of  the  utmost 
cleanliness  as  regards  the  clothing,  hands  of  the  invalid,  bed-clothes, 
floor,  and  rugs.  The  hands  of  the  attendant,  as  well  as  the  patient, 
should  be  kept  absolutely  clean  at  all  hazards.  All  articles  of  soiled 
linen  which  are  not  to  be  destroyed,  should  be  brought  into  immedi- 
ate contact  with  a  5  per  cent,  solution  of  phenol  or  immersed  for 
several  hours  in  a  solution  of  corrosive  sublimate  and  subsequently 
boiled.  The  solution  may  be  made  by  dissolving  a  dram  each  of  corro- 
sive sublimate  and  ammonium  muriate  in  a  gallon  of  water  contained 
within  a  wooden  bowl  or  tub.  This  solution  may  also  be  used  for 
washing  floors,  walls,  or  wooden  furniture.  In  institutions  sterilization 
plants  are  essential  for  a  proper  cleansing  of  the  linen. 

The  furniture  of  the  sick-room  should  be  as  simple  as  possible. 
Draperies,  lace  curtains,  velvet  or  plush  furniture,  antl  all  articles 
likely  to  retain  dust  should  be  excluded.  It  is  desirable  to  clean  the 
room,  if  possible,  only  when  the  patient  is  out-of-doors.  Care  should 
be  taken  not  to  dust  with  feather-dusters  or  to  sweep  vigorously  with 
a  dry  broom.  The  rugs  should  be  cleaned  in  the  open  air,  and  dusting 
should  be  performed  only  with  a  moist  cloth.  There  should  be  no 
carpet  in  the  room  occupied  by  a  consumptive. 

It  is  properly  one  of  the  prerogatives  of  health  officials  to  supervise 
effective  methods  of  disinfection  of  apartments,  after  the  death  or 
removal  of  the  consumptive.  Much  has  been  written  of  late  concerning 
the  necessity  of  disinfecting  such  rooms  and  the  contained  furniture  at 
public  expense.  The  movement  relative  to  the  destruction  or  disinfection 
of  all  articles  with  which  the  invalid  has  come  in  contact  has  extended 
sufficiently  to  inspire  on  the  part  of  certain  students  and  educators 
an  advocacy  of  cremation.  It  is  well  in  this  connection  to  call  attention 
to  the  fact  that  the  administrative  control  of  tuberculosis  pertains  far 


THE    SUPERVISION    AND    EDUCATION    OF    THE    CONSUMPTIVE         575 

more  to  the  supervision  of  the  consumptive,  and  his  immediate  environ- 
ment while  he  is  yet  alive,  and  disseminating  innumerable  agents  of 
infection,  than  to  the  disposal  of  his  body  after  the  potent  source  of 
danger  has  ceased  to  exist.  As  a  matter  of  fact,  an  insistence  upon 
strict  precautionary  measures  relating  to  personal  cleanliness  and  the 
hygiene  of  the  sick-room  during  life  is  of  infinitely  more  importance 
than  the  disinfection  of  apartments  and  the  destruction  of  their  con- 
tained articles  after  death.  It  would  appear,  however,  that  both  the 
profession  and  the  public  are  educated  more  or  less  to  a  belief  in  the 
wisdom  of  rigid  disinfection  of  apartments  occupied  by  consumptives. 
Frequently,  however,  no  particular  concern  is  manifested  as  to  their 
immediate  presence  in  the  family  for  prolonged  periods.  Disinfection  of 
apartments  by  no  means  is  to  be  deprecated,  but  the  thought  is  suggested 
that  in  some  instances  the  importance  of  this  procedure  is  exaggerated. 
As  suggested  by  Chapin,  disinfection  should  not  be  regarded  as  an 
expiatory  atonement  for  previous  unsanitary  sins.  It  is  particularly 
to  be  recommended  in  crowded  tenements  exhibiting  a  sad  deficiency 
of  sunlight  or  fresh  air,  and  occupied  by  the  ignorant,  impoverished, 
and  sometimes  the  vicious.  Disinfection,  when  done  at  all,  should 
be  practised  in  a  most  thorough  manner,  and  may  be  performed  by 
the  burning  of  sulphur  or  foimaldehyd.  Formaldehyd  disinfection 
is  the  more  modern,  and  probably  the  more  efficient,  method.  The 
key-holes,  window-cracks,  fire-places,  door  apertures,  and  all  other 
crevices  should  be  tightly  sealed.  Articles  of  clothing  or  bedding 
should  be  spread  or  suspended  in  the  room  in  order  that  the  disinfec- 
tion may  be  as  thorough  as  possible. 

The  most  convenient  manner  of  formaldehyd  disinfection  results 
from  the  use  of  the  generator.  As  commonly  employed,  however,  the 
formaldehyd  is  sprinkled  upon  a  sheet  and  suspended  upon  a  clothes- 
line. There  should  be  used  one  pint  of  formaldehyd  to  every  1000 
cubic  feet  of  air,  and  the  room  tightly  closed  for  at  least  twelve 
hours  in  order  to  make  fumigation  as  thorough  as  possible.  Much 
of  the  clothing,  bedding,  and  sometimes  the  rugs  may  be  disinfected 
by  placing  in  a  steam  sterilizer.  If  sulphur  is  used,  it  should  be 
placed  in  an  iron  vessel,  which  in  turn  is  put  into  a  tub  partly  filled 
with  water.  The  iron  kettle  should  stand  upon  bricks  placed  in  the 
bottom  of  the  tub.  About  three  pounds  of  powdered  sulphur  should 
be  used  for  every  1000  cubic  feet  of  air.  After  the  sulphur  has  been 
ignited,  the  room  should  be  tightly  closed,  and  remain  unopened  for 
from  ten  to  twelve  hours.  If  sulphur  candles  are  employed,  there  is 
considerable  danger  that  the  disinfection  will  be  incomplete  unless 
several  candles  are  burned  at  the  same  time  in  a  small  room.  The 
walls,  window-frames,  and  other  wooden  portions  of  the  room  should 
be  thoroughly  washed  with  the  disinfecting  solution  previously 
described. 

Further  considerations  relating  to  the  care  of  the  consumptive, 
the  hygiene  of  the  room,  and  the  importance  of  detailed  in.structions 
in  the  interests  of  the  invalid  will  be  discussed  in  connection  with 
the  following  subdivision. 


576  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

CHAPTER  LXXXV 

THE    EXTENSION  OF   MATERIAL   AID   ACCORDING   TO 

THE  VARYING  NEEDS  AND  REQUIREMENTS  OF 

DIFFERING  CLASSES 

An  organized  effort  toward  the  suppression  of  consumption,  to  be 
effective,  must  take  cognizance  of  the  obligation  imposed  upon  society 
to  render,  when  needed,  substantial  assistance  to  sufferers  from  the 
disease.  The  movement  for  the  restriction  of  tuberculosis  must  not 
be  permitted  to  assume  the  characteristics  of  a  "crusade"  against 
the  indi\idual  consumptive,  but  rather  against  the  conditions  which 
make  possible  the  existence  of  the  scourge.  There  must  be  a  campaign 
against  tuberculosis  rather  than  the  tuberculous.  Both  for  the  attain- 
ment of  the  best  results  in  prophylaxis  and  for  humanitarian  reasons 
the  attitude  of  society,  as  clirected  largel}'  by  the  mecUcal  profession, 
must  not  partake  of  oppression  and  persecution.  Arbitrary  measures 
are  demanded  oiilj'  by  the  exigencies  of  unusual  cases.  Upon  the 
other  hand,  the  predominating  spirit  actuating  all  attempts  of  adminis- 
trative control  should  be  that  of  benignanc}-,  supervisory  helpfidness, 
and  material  aid. 

The  first  appeal  for  assistance  arises  from  the  great  mass  of  needy 
consumptives  who  are  confined  to  their  homes.  To  such  a  class,  instruc- 
tions as  to  the  sanitary  disposal  of  sputum  and  the  hygiene  of  the  room 
are  of  but  slight  value  unless  means  are  provided  to  permit  their  proper 
execution.  In  other  words,  practical  aid  to  the  ignorant  and  impover- 
ished constitute  an  essential  factor  in  the  general  scheme  of  supervision 
surely  no  less  important  than  the  distribution  of  educational  leaflets 
and  the  periodic  visits  of  nurses  and  inspectresses.  The  benefits  derived 
as  a  result  of  the  visiting  nurses'  association  and  similar  organizations, 
though  manifold,  can  be  greatly  augmented  by  the  disbursement,  under 
their  direction,  of  sputum-cups,  gauze,  di-sinfectants,  or  other  material 
used  for  the  purposes  of  prevention.  The  cost  is  utterly  insignificant  in 
comparison  with  the  results  to  be  obtained,  and  the  same  is  true  of  the 
expense  necessary  to  supply  deficiencies  in  the  way  of  food  or  clothing 
in  individual  cases.  At  least  fresh  eggs  and  milk  should  he  freely 
furnished  to  the  very  poor.  By  this  means  not  only  are  there  afforded 
additional  opportunities  for  the  restoration  of  working  power  and  sub- 
secjuent  maintenance  of  families,  but  also  greater  assurances  of  compli- 
ance with  precautionary  rules.  Among  the  destitute  the  proliability  of 
faithful  cooperation  on  the  part  of  invalid  or  family  is  much  enhanced 
if  there  are  sustained  relations  of  mutual  reciprocity.  The  advanced 
consumptive  who,  in  ignorance  and  poverty,  is  destined  to  succumb  to 
prolonged  illness  at  hotne  represents  by  all  odds  the  greatest  source  of 
danger  as  regards  the  transmission  of  the  disease  to  others.  Assuredly 
no  investment  can  }-ield  a  more  substantial  return  than  the  extension 
of  material  aid  to  such  a  class,  in  the  hope  of  thereby  diminishing  the 
possibilities  of  contagion. 

Assistance  to  these  people  should  also  include  the  distribution 
of  needful  articles  of  clothing  and  such  medicines  as  are  demanded 
under  the  sanction  of  the  visiting  nurse  or  other  official  representatives. 
Provision  should  be  made  for  the  proper  cleansing  of  rooms  and  cloth- 


EXTENSION  OF    MATERIAL    AID    ACCORDING    TO    VARYING    NEEDS      577 

ing,  the  cost  of  frequent  scrubbings  of  the  floor  and  washing  of  the 
linen  being  defrayed  at  public  expense. 

Not  the  least  important  province  of  the  nurse  or  inspectress  in  the 
interest  of  the  patient  is  a  supervision  of  the  immediate  environment. 
Although  often  a  matter  of  techous  detail,  the  advantages  of  a  proper 
attention  to  the  surroundings  are  almost  incalculable.  An  intelligent 
and  resourceful  inspection  of  apartments  often  affords  means  for  an 
■out-of-door  existence  which  would  at  first  be  considered  as  impossible 
of  attainment.  Recourse  may  be  taken  to  back  porches,  i-oofs  of  tene- 
ment houses,  tents,  and  improvised  aeraria,  by  means  of  which  simple 
■contrivances  the  invalid  is  permitted  to  partake  of  the  benefits  of  fresh 
air  and  sunshine.  If  the  patient  is  unable  to  stay  out-of-doors,  the 
mere  supervision  of  the  sick-room  is  sometimes  fraught  with  important 
benefits.  The  selection  of  a  room  containing  the  greatest  facilities  for 
ventilation,  and  with  a  simny  exposure,  falls  entirely  within  the  scope 
of  visiting  supervision,  as  does  even  the  arrangement  of  the  furniture, 
■the  situation  of  the  bed  near  an  open  window,  the  adjustment  of  tem- 
perature, and  the  regulation  of  the  amount  and  character  of  bed- 
covering.  Attention  to  the  foregoing  considerations  involves  but  slight 
■expense,  while  a  devotion  to  detail  adds  immeasurably  to  the  material 
comfort  of  the  sufferer  and  insures,  as  a  rule,  conformity  to  precaution- 
.ary  instructions.  An  important  advantage  of  systematic  periodic  vis- 
itation is  the  opportunity  permitted  to  acquire  accurate  data  as  to  the 
sanitary  conditions  and  the  probable  dangers  of  infection  to  others. 
Upon  this  evidence  may  be  based  any  action  leading  to  the  forcible 
removal  of  the  patient  to  special  institutions. 

INSTITUTIONS  FOR  CONSUMPTIVES 

From  the  aspect  of  prophijlaxis,  institutional  care  and  supervision 
are  demanded  by  three  fairly  distinct  classes  of  pulmonary  invalids: 

(a)  The  hopelessly  ill  and  impoverished. 

(b)  The  vicious,  who  refuse  to  conform  to  established  rules. 

(c)  The  consumptive  poor,  who,  with  suitable  assistance,  offer  a 
reasonable  prospect  of  recovery. 

No  inclusion  is  made  of  the  non-inchgent  incipient  class,  for  whom 
■especially  sanatorium  provision  has  been  provided.  Without  the 
slightest  reflection  upon  the  usefulness  of  institutions  open  only  to 
patients  with  slight  infection  and  in  comfortable  circumstances,  the 
fact  remains  that  from  the  standpoint  of  prevention  such  patients  do 
snot  comprise  a  group  constituting  important  elements  of  danger  to 
others.  The  construction  of  sanatoria  for  incipient  non-charity  cases 
in  the  interests  of  prophylaxis  does  not  represent  a  legitimate  obligation 
upon  society.  The  proper  scope  of  such  institutions  will  not  be  con- 
sidered at  this  time,  but  will  be  reserved  for  later  discussion  in  con- 
nection with  Treatment. 

The  Hopelessly  111  and  Impoverished. — For  the  very  advanced 
cases,  it  is  clearly  incumbent  upon  society  to  provide  segregation  hos- 
pitals where  the  last  comforts  of  life  can  be  administered  without  the 
slightest  danger  to  families  or  the  community,  and  where  death  may 
be  robbed  of  a  portion  of  its  horrors  through  judicious  nursing  and 
medical  care.  The  destitute  and  dying  consumptive  who  is  not  granted 
&  welcome  in  municipal  hospitals  open  to  other  classes  of  suffering 


578  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

humanity,  and  is  even  denied  admission  to  special  sanatoria,  is  entitled, 
upon  humanitarian  grounds,  to  receive  from  the  Commonwealth  insti- 
tutional aid  when  needed.  In  turn,  society  has  the  right,  at  the  discre- 
tion of  the  health  officers,  to  insist  upon  the  forcible  removal  of  hopeless 
cases  to  such  institutions  when  sanitary  precautions  are  wantonly  or 
unavoidably  disregarded.  All  municipalities  should  provide  adequate 
facilities  for  the  housing  and  care  of  these  indigent  advanced  cases 
under  the  supervision  of  the  health  departments.  In  the  campaign  of 
prevention  the  great  usefulness  of  institutions  of  this  character  must  be 
appreciated  by  those  who  have  become  at  all  familiar  with  the  deplorable 
conditions  existing  in  large  cities.  The  number  of  patients  properly 
falling  within  the  scope  of  hospitals  for  advanced  and  impoverished 
cases  is  legion.  But  little  provision  has  thus  far  been  made  for  such 
unfortunates,  as  sanatoria  possessing  facilities  for  their  care  are  exceed- 
ingly few.  From  an  institutional  standpoint  these  invalids  are  unde- 
sirable because  of  the  nature  of  their  physical  infirmity,  and  by  virtue 
of  their  ignorance,  destitution,  and  obstinacy.  It  is  probable  that 
many  would  object  strenuously  to  detention  in  special  institutions,  and 
very  likely  would  refuse  to  conform  to  established  rules,  and  it  is  pre- 
cisely for  such  consumptives  that  some  form  of  sanatorium  provision  is 
demanded.  It  is  not  merely  the  hopeless  indigent  invalid  who  remains 
at  home,  a  constant  menace  to  the  immediate  family  and  associates, 
whom  it  is  desired  to  remove  to  special  hospitals,  but  also  the  great 
army  of  homeless,  roving,  shiftless,  iiitemperate.  and  vnndi/  consumptives 
who  are  notoriously  neiiligont  regarding  sanitary  instructions. 

The  Vicious  Who  Refuse  to  Conform  to  Established  Rules. — This, 
of  all  classes,  undoubteiUy  represents  l.iy  far  the  greatest  danger  to  so- 
ciety on  account  of  the  wide-spread  distribution  of  bacUli  resulting  from 
reckless  expectoration.  The  cases  comprising  this  group  of  vicious, 
dissipated,  or  unmanageable  consumptives  are  radically  different  from 
those  embraced  in  the  preceding  class.  The  thought  is,  therefore,  sug- 
gested that  there  may  properly  be  displayed  a  corresponding  difference 
in  the  character  of  the  sanatoria  prepared  for  these  two  classes  of  in- 
digent invalids.  WhOe  unnecessary  multiplication  of  institutions  mu.st 
be  avoided,  it  is,  indeed,  a  reflection  upon  modern  civilization  to  crowd 
these  two  groups  indiscriminately  in  poorly  ventilated  and  sometimes 
loathsome  poorhouses. 

Adequate  accommodations  should  be  provided  for  worthy  advanced 
consumptives  without  an  enforced  intimate  association  with  the  vicious 
and  dissipated.  The  hospital  for  advanced  cases  should,  indeed,  be  a 
refuge  in  literal  compliance  with  the  spirit  of  the  German  institutions, 
i.  e.,  "Friedensheim,"  or  "  Home  of  Peace." 

It  is  apparent  that,  in  the  interests  of  humanity,  separate  provision 
should  be  made  for  those  le.ss  entitled  to  sympathetic  consideration. 
Neither  does  it  appear  that  the  common  jail  is  quite  the  appropriate 
place  even  for  those  who  infringe  upon  the  rights  of  society.  Although 
admittedly  violators  of  the  law  and  entitled  for  this  reason  to  no  more 
consideration  than  other  criminals,  the  fact  remains  that  they  do  not 
come  under  precisely  the  same  category  and,  therefore,  should  not  be 
given  a  similar  penalty.  It  is  apparent  that  the  punishment  to  be 
allotted  to  offenders  against  criminal  law,  even  if  tuberculous,  should 
bear  no  relation  to  their  physical  infirmity.  It  is  equally  true  that 
miiui  infringement  of  sanitary  laws  by  consumptives  cannot  justify, 


EXTENSION    OF    MATERIAL    AID    ACCORDING    TO    VARYING    NEEDS       579 

even  in  the  interests  of  prevention,  the  imposition  of  an  indefinitel ij 
prolonged  jail  sentence. 

Experience  has  shown  that  tuberculosis  is  already  frequent  among 
those  incarcerated  for  other  crimes  in  penal  institutions.  It  would, 
indeed,  be  a  short-sighted  policy  to  crowd  jails,  reformatories,  and 
prisons  with  unruly  consumptives.  In  such  an  event  it  is  difficult  to 
conceive  in  what  manner  either  the  purposes  of  justice  or  the  cause  of 
prevention  could  be  effectually  subserved.  The  vast  number  of  such 
individuals  would  preclude  their  proper  housing  under  State  supervision. 
The  responsibility  for  their  management  and  control  should  be  assumed 
by  the  local  communities  burdened  by  their  presence,  as  pi'ovision  can 
be  made  with  but  comparatively  slight  expense  for  their  proper  housing. 
It  is  not  insisted  that  a  necessity  exists  for  the  construction  of  special 
detention  institutions  for  these  patients,  but  it  is  contended  that 
separate  ■provision  for  their  reception  should  be  made  either  upon  the 
county  farms,  or  in  special  wards  in  existing  hospitals  for  advanced 
cases. 

It  is  perfectly  feasible  to  construct  suitable  accommodations  upon 
the  town  farm  for  the  care  of  worthy  hopeless  consumptives,  as  well 
as  for  the  vicious  and  unmanageable.  Appropriate  wards  or  camps  may 
be  set  aside  to  comply  with  the  separate  needs  and  requirements  of  each 
class.  Such  institutions,  if  conducted  under  the  supervision  of  local 
health  authorities,  would  aid  greatly  in  the  accomplishment  of  practical 
prophylactic  results.  All  communities  should  be  compelled  to  extend 
aid  of  this  character  to  the  hopeless  impoverished  consumptive  and 
exact  in  return  strict  compliance  with  the  law  on  the  part  of  others. 

The  Consumptive  Poor  Who,  With  Proper  Assistance,  Offer 
Reasonable  Prospects  of  Recovery. — Many  of  the  people  included 
in  this  group,  as  a  result  of  substantial  assistance,  can  resume  their 
former  positions  as  wage-earners.  As  a  rule,  they  are  unable  in  their 
ordinary  environment  to  observe  precautionary  rules,  and  hence  become 
with  advancing  infection  a  distinct  menace  to  the  community.  There 
can  be  no  question,  therefore,  as  to  the  obligation  devolving  upon 
society  to  care  for  its  non-hopeless  indigent  consumptives.  The  eco- 
nomic feature  of  the  problem  has  been  considered.  The  responsibility 
devolving  upon  the  Commonwealth  can  be  discharged  only  by  the  erec- 
tion of  State  sanatoria  or  convalescent  farms  for  those  whose  condition 
requires  institutional  regime,  and  by  the  construction  of  free  tubercu- 
losis dispensaries  in  thickly  settled  communities  for  the  ambulant  cases. 

STATE    SANATORIA 

The  maintenance  of  State  sanatoria  for  partly  indigent  incipient 
cases  has  been  amply  justified  by  the  results  thus  far  accomplished  in 
several  localities,  in  which  the  experiment  has  been  tried,  notably  in 
Massachusetts.  In  emulation  of  the  example  set  at  Rutland,  the 
pendulum  of  public  opinion  is  swinging  strongly  toward  the  erection 
of  such  institutions.  Neither  the  charitable  features  nor  the  economic 
utility  of  sanatoria  of  this  kind  are  subject  to  doubt  even  among  the 
most  skeptical.  There  is  room,  however,  for  honest  differences  of 
opinion  as  to  the  jurisdiction  under  which  they  should  be  operated,  the 
manner  of  construction,  location,  the  extent  of  industrial  opportunities 
offered,  and  the  character  of  the  management.     From  a  practical  stand- 


580  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

point  it  matters  little  whether  these  institutions  are  supported  by  State 
aid  or  by  local  public  or  pri\'ate  benevolence,  provided  the  true  spirit 
ostensibly  inspiring  their  construction  is  conscientiously  maintained  by 
those  in  charge.  This,  unfortunately,  is  not  always  the  case  in  public 
institutions  on  account  of  the  pernicious  influence  of  politics. 

The  selection  of  the  site  is  sometimes  grossly  inappropriate  and 
unnecessarily  expensive.  Buildings  ill  adapted  for  the  purpose  are 
occasionally  erected  through  the  advice  of  partizan  architects.  Grossly 
incompetent  medical  superintendents  may  be  selected  as  a  result  of 
political  favor.  There  may  result,  therefore,  a  great  diminution  in  the 
actual  usefulness  of  institutions,  endowed  with  almost  infinite  possi- 
bilities in  the  way  of  service  to  others. 

The  essential  considerations  are  that  these  buildings  should  be 
properly  located,  so  designed  and  constructed  as  to  afford  suitable 
accommodations  to  the  gi-eatest  number  at  a  nominal  expense,  and  con- 
ducted in  accordance  with  broadly  humanitarian  instincts  as  well  as 
along  scientific  lines.  To  this  end  it  is  obvious  that  the  best  results  can 
be  secured  only  through  the  active  cooperation  of  representative  medical 
men.  It  is  quite  impracticable  to  expect  from  a  Committee  of  the 
Legislature,  rendering  allegiance  primarily  to  some  political  ring,  the 
elaboration  of  modern  well-sustained  ideas  concerning  the  construction 
and  maintenance  of  sanatoria.  Upon  such  a  subject  there  must  be 
brought  to  bear  the  enlightenment  and  experience  of  those  especially 
engaged  in  medical  and  sociologic  work.  The  responsibility  for  the 
erection  and  supervision  of  such  institutions  should  be  delegated  to 
members  of  the  medical  profession  interested  in  the  elucidation  of 
problems  of  this  nature.  Through  the  cooperation  of  State  and  county 
medical  societies,  associations  for  the  study  and  prevention  of  tuber- 
culosis, the  various  charity  organizations,  and  the  local  health  authorities, 
the  direction  of  these  institutions  may  be  consigned  to  individuals  who 
are  perfectly  competent  to  discharge  satisfactorily  the  imposed  trust. 
It  is  probable  that  the  practical  efficiency  of  sanatoria  designed  for  this 
purpose  would  be  greatly  increased  if  they  were  erected  in  various  com- 
munities throughout  the  State,  supported  in  the  main  by  local  subscrip- 
tions, yet  receiving  substantial  aid  from  the  State.  Irrespective  of  the 
amount  of  assistance  rendered  by  private  benevolence,  it  is  undoubtedly 
true  that  more  satisfying  results  would  accrue  from  the  distribution  of 
several  institutions  of  this  nature  in  different  localities,  than  from  the 
erection  of  a  single  imposing  structure  for  indigent  consumptives.  It 
goes  without  saying  that  a  single  building  of  this  description,  no  matter 
of  what  size,  must  be  entirely  inadequate  to  supply  the  pressing  needs 
of  the  many  unfortunate  sufferers  scattered  throughout  a  State.  It  is 
also  true,  in  spite  of  the  insufficient  accommodations,  that  but  little 
stimulus  would  be  given  to  the  extension  of  further  aid  either  through 
local  pride  or  private  philanthropy.  The  logical  solution  rests  with  the 
creation  of  so  advanced  a  public  sentiment  as  will  inspire  the  construc- 
tion of  numerous  abodes  of  this  character  for  early  consumptives  who 
have  not  the  means  of  self-support. 

It  is  to  be  regi-etted  also  that  buildings  erected  entirely  through 
private  generosity,  though  of  beautiful  architectural  design  and  mag- 
nificent in  proportions,  are  often  ill  suited  to  the  needs  and  require- 
ments of  the  comparatively  small  number  of  indigent  consumptives 
who  chance  to  be  admitted  within  their  walls.     Meanwhile  the  expense 


EXTENSION    OF    MATERIAL    AID    ACCORDING    TO    VARYING    NEEDS      581 

incident  to  these  monumental  structures  is  entirely  out  of  proportion 
to  the  practical  benefits  to  be  secured. 

The  question  of  affording  industrial  facilities  to  the  inmates  of 
State  sanatoria  is  very  properly  subject  to  some  comment.  As  fur- 
nishing a  means  of  diversion  to  those  not  likely  to  be  injured  by  such 
pursuits,  there  is  undoubtedly  much  to  recommend  the  performance 
of  light  out-of-door  work,  either  in  the  fields  or  garden,  and  of  handiwork 
of  various  kinds  while  at  rest  upon  the  porches.  Indoor  employment 
should  be  deprecated  under  all  circumstances.  Many  of  the  arts  and 
crafts,  even  if  practised  in  sunny,  well-ventilated  apartments,  exercise  a 
distinctly  deleterious  effect  on  account  of  the  confinement,  physical 
effort,  and  inhalation  of  dust.  Upon  the  other  hand,  work  in  the  fields, 
garden,  or  at  the  wood-pile  is  often  attended  by  unfortunate  conse- 
quences. Compulsory  employment  of  this  kind  is  not  likely  to  be 
received  with  the  utmost  enthusiasm  even  by  individuals  participating 
in  the  bounties  of  State  or  private  philanthropy. 

The  provision  for  industrial  pursuits  may  not  be  expected  to  furnish 
financial  assistance  to  public  or  private  institutions  of  this  character. 
As  a  source  of  income,  pure  and  simple,  any  scheme  of  organized 
work  is  not  to  be  recoinmended ,  as  the  industrial  features  cannot  be 
expected  to  yield  a  financial  return  at  all  commensurate  with  the 
expenditure.  Carefully  selected  patients  may  be  permitted  to  perform 
such  light  work  upon  the  premises  for  brief  periods  of  time,  as  their 
physical  condition  will  justify,  but  any  organized  effort  toward  increasing 
the  income  through  the  labor  of  patients  is  utter  folly.  Assuredly  one 
of  the  important  objects  of  such  institutions  wiil  be  defeated,  unless 
the  inmates  are  constantly  subjected  to  the  closest  surveillance  in 
order  to  forestall  the  possiliilitu  oj  orerexertion. 

The  Influence  of  State  Sanatoria  upon  Neighboring  Com- 
munities and  Surrounding  Property. — It  is  important  to  call  attention 
to  these  features  connected  with  the  erection  of  hospitals  for  advanced 
cases,  concerning  which  there  has  been  considerable  popular  misappre- 
hension. The  impression  has  become  somewhat  prevalent  that  residents 
of  smaller  towns,  in  which  have  been  situated  sanatoria  for  consumptives, 
have  been  subject  to  more  or  less  danger  of  contagion  from  the  influx 
of  imported  cases. 

In  the  consideration  of  the  possible  danger  of  infection  from  visiting 
tuberculous  invalids,  it  is  well  to  discriminate  clearly  between  the  influ- 
ence of  so-called  closed  sanatoria,  and  that  of  open  resorts  for  consump- 
tives. The  evidence  thus  far  presented  is  quite  overwhelming  to  the 
effect,  that  the  closed  institutions  are  everywhere  responsible  for  a 
material  diminution  in  the  tuberculosis  mortality  rate  among  the 
neighboring  inhabitants.  This  is  explained  by  the  pronounced  educa- 
tional influence  exerted  throughout  the  community  by  lessons  in 
hygienic  living,  and  the  precautionary  measures  taught  through  the 
force  of  actual  example.  The  development  of  tuberculosis  among 
physicians,  nurses,  and  attendants  in  institutions  for  consumptives 
is  known  to  be  exceptionally  rare,  in  spite  of  prolonged  intimate  asso- 
ciation with  invalids  in  advanced  stages  of  the  disease.  Upon  the 
acceptance  of  these  facts,  it  is  difficult  to  conceive  how  the  resident 
population  of  towns  in  which  such  institutions  are  located,  are  especially 
liable  to  infection,  the  exposure  being  practically  nil  and  the  measures 
of  prevention  being  thoroughly  understood.     As  a  matter  of  fact,  the 


582  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

existence  of  well-conducted  tuberculosis  hospitals  in  any  community 
must  serve  as  an  added  element  of  protection  to  the  public  rather  than 
as  a  menace. 

As  regards  the  open  resorts,  where,  on  account  of  climatic  advantages, 
pulmonary  invalids  in  advanced  stages  of  the  disease  flock  in  large 
numbers,  there  might  be  expected,  upon  purely  theoretic  grounds, 
a  possible  increase  of  the  non-imported  tuberculosis  mortality  rate. 
Certain  towns  in  Europe,  notably  Mentone  and  Nice,  have  frequently 
been  cited  as  illustrating  the  development  of  indigenous  tuberculosis 
among  the  inhabitants  from  the  importation  of  pulmonary  invalids. 
The  reports  from  these  places  as  to  the  prevalence  of  local  infection 
are,  however,  decidedly  at  variance.  The  observations  of  experienced 
clinicians  in  other  health  resorts  of  Europe  and  America  are,  however, 
singularly  in  accord  as  to  the  entire  lack  of  statistical  data  upon  which 
to  base  the  assumption  of  an  increase  in  the  practical  dangers  of  infection 
from  the  influx  of  consumptives.  Communications  from  St.  Moritz, 
Davos  Platz,  and  Cairo  concur  in  positive  statements  concerning  the 
lack  of  evidence  as  to  the  increase  of  tuberculosis  among  the  native 
population  at  any  time  during  recent  years. 

In  1905  an  inquiry  was  conducted  by  Dr.  C.  F.  Gardiner  as  to  the 
influence,  if  any,  of  imported  pulmonary  invalids  upon  the  native  tuber- 
culosis death-rate  in  open  resorts  throughout  Massachusetts,  Connecticut, 
New  York,  North  and  South  Carolina,  Virginia,  Georgia,  Texas,  New 
Mexico,  Arizona,  Utah,  California,  and  Colorado.  The  result  of  this 
inquiry  showed  conclusive!}'  that  the  imported  tuberculous  invalid  was 
scarcely  ever  a  source  of  danger  to  the  native  population,  and  that  the 
practical  likelihood  of  such  infection  in  open  resorts  was  grossl}-  exag- 
gerated. It  must  be  insisted,  in  spite  of  such  reports,  that  the  pro- 
tection of  these  communities  is  dependent  largely  upon  the  vigilance  of 
the  health  authorities  and  the  effectiveness  of  their  administration. 
Gardiner  has  reported  that  an  investigation  conducted  by  himself  and 
other  physicians  in  Colorado  Springs,  including  different  liealth  officers, 
has  disclosed,  out  of  a  population  of  approximately  2().()()()  people,  but 
one  case  each  year  since  1889  originating  among  the  native  population, 
or  sixteen  cases  in  sixteen  3'ears  in  spite  of  an  exceedingly  large  number 
of  imported  pulmonary  invalids.  My  own  observations  in  the  city  of 
Denver  during  a  period  of  sixteen  years  have  been  reported  in  connection 
with  the  Geogi'aphic  Distribution  of  Tuberculosis. 

No  valid  objection  can  he  presented  to  the  erection  of  hospitals  for 
tuberculous  patients  upon  the  score  of  fancied  dangers  to  the  com- 
munity. Strenuous  opposition  may  sometimes  be  interposed  as  to  their 
erection,  but  this  usuallj^  emanates  from  propertj'-owners  in  the  imme- 
diate vicinity,  who  assume  that  values  will  be  unfavorably  affected 
by  the  proximity  of  such  institutions.  This  element  of  deterioration 
in  the  value  of  surrounding  property,  which  is  more  imaginary  than 
real,  cannot  obtain  when  a  site  is  chosen  either  in  the  country  or  in  the 
suburbs  of  the  larger  cities.  On  the  other  hand,  it  has  been  found 
that  the  presence  of  these  institutions  has  been  decidedly  helpful 
rather  than  unfavorable.  In  almost  all  instances  surrounding  property 
has  appreciated  in  value  through  the  increase  of  population  in  localities 
previously  isolated  or  abandoned.  With  increase  of  visitors  there 
necessarily  takes  place  expansion  of  business  of  all  kinds,  improvement 
of  adjacent  property,  with  attention  to  the  locality  as  a  healthful 


EXTENSION    OF    MATERIAL    AID    ACCORDING    TO    VARYING    NEEDS      583 

and  desirable  place  of  resort.  Prejudice  and  preconceived  ideas  as 
to  the  supposed  undesirability  of  institutions  of  this  kind,  founded 
upon  misconceptions  of  actual  facts,  should  not  be  permitted  to  thwart 
the  important  interests  either  of  the  Commonwealth  or  of  pulmonary- 
invalids  as  a  class.  Considerations  pertaining  to  the  location  of  san- 
atoria, hygienic  conditions,  immediate  surroundings,  water-supply, 
soil,  drainage,  accessibility,  initial  expenditure,  and  cost  of  maintenance 
will  be  considered  in  connection  with  the  Sanatorium  Treatment  of 
Consumption.  It  is  submitted  at  this  time,  however,  that  institutions 
designee!  for  indigent  cases  do  not  require  an  elaborate  outlay  for 
buildings,  and  that  a  suitable  selection  of  the  site,  with  provision  for 
the  largest  possible  number  of  inmates,  is  of  far  greater  importance 
than  the  erection  of  imposing  structures.  Institutions  non-charitable 
in  character  and  not  maintained  at  public  expense  may  be,  of  course,  as 
ornate  and  magnificent  as  their  promoters  desire. 

THE  TUBERCULOSIS  DISPENSARY 

One  of  the  most  important  factors  in  a  supervisory  and  educational 
campaign  is  the  tuberculosis  dispensary.  While  its  province  is  more 
directly  for  ambulant  cases  than  for  others,  its  scope  is  surprisingly 
far  reaching.  Upon  superficial  inquiry  it  might  appear  that  the 
necessity  of  special  dispensaries  for  tuberculous  patients  does  not  exist, 
and  that  this  feature  could  be  safely  delegated  to  the  other  free  dis- 
pensaries, so  common  in  large  municipalities.  This  aspect  of  the  move- 
ment toward  the  prevention  and  control  of  consumption  has  been 
regarded  by  some  as  subordinate  to  many  other  phases  of  the  campaign. 
In  truth,  however,  the  ultimate  influence  of  the  tuberculosis  dispensary 
is  almost  beyond  estimation.  Its  usefulness  is  not  confined  merely 
to  the  rendering  of  routine  gratuitous  assistance  to  consumptives,  but 
more  to  the  opportunity  afforded  for  personal  contact  with  the  pul- 
monary invalid  in  his  home,  the  inspection  and  control  of  his  environ- 
ment, and  the  imparting  of  responsible  instructions.  Among  the  varied 
functions  of  such  an  institution  there  should  be  recognized  its  peculiar 
position  as  the  central  point  of  all  other  agencies  engaged  in  the  pre- 
vention of  the  disease.  In  other  words,  it  often  represents  the  initial 
step  in  the  acquirement  of  data  regarding  centers  of  infection. 

To  R.  W.  Phillip,  of  Edinburgh,  are  students  of  preventive  medicine 
indebted  for  the  present  conception  of  the  unique  province  of  the  ' 
tuberculosis  dispensary.  Through  his  individual  efforts  there  was 
founded,  in  1887,  the  Victoria  Dispensary  for  Consumption  in  Edinburgh, 
the  first  institution  of  this  kind  in  existence.  Since  then  similar 
buildings  have  been  constructed  in  Belgium,  France,  and  Germany, 
and  a  few  cities  of  the  United  States.  The  underlying  motive  inspiring 
the  founding  of  the  \'ictoria  Dispensary  by  private  charitable  enterprise 
was  not  so  much  the  care  of  patients  applying  for  treatment  nor  the 
possible  amelioration  or  cure  of  the  disease.  It  was  hoped  to  obtain  a 
more  ready  access  to  centers  of  infection  in  families  and  lodging-houses, 
in  order  that  a  more  comprehensive  supervision  of  infected  dwellings 
might  prevail  and  the  general  scheme  of  prophylaxis  become  more 
effective. 

In  Scotland,  unlike  other  countries,  the  tuberculosis  dispensary  ante- 
dated the  erection  of  saruitoria,  antl  has  remained  not  merely  an  isolated 


584  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

feature  of  the  tuberculosis  movement,  but  has  gradually  developed  into 
the  most  important  integral  part  of  the  entire  system  of  organized  effort. 
It  should  be,  in  fact,  a  clearing-house  for  all  indigent  consumptives, 
from  which,  after  thorough  examination  of  the  physical  conditions  and. 
environment,  they  may  be  sent,  when  necessary,  to  appropriate  institu- 
tions. The  province  of  the  tuberculosis  dispensary  as  a  sort  of  general 
bureau  of  information  may  be  subdivided  for  the  following  purposes: 

1 .  Invitation  of  indigent  tuberculous  patients  and  those  presenting 
suspicious  evidence  of  the  disease. 

2.  Thorough  physical  examination  of  all  comers,  with  bacteriologic 
analysis  of  the  sputum  and  the  preservation  of  a  detailed  record  of  the 
family  history,  previous  history,  present  illness,  occupation,  residence, 
and  environment.  In  this  manner  there  is  obtained  an  accurate  diag- 
nosis of  the  condition,  the  early  recognition  of  the  disease  representing 
one  of  the  most  important  elements  in  the  war  of  prevention. 

3.  Facilities  offered  for  the  imparting  of  competent  instructions  to 
patients,  and  for  the  inspection  of  dwellings  and  workshops.  In  addition 
to  personal  advice  and  exhortation  to  obey  instructions,  circular  infor- 
mation may  be  distributed  in  \-arious  languages,  as  previously  described. 

4.  Opportunity  for  the  inclusion  of  the  case  in  a  list  of  those  to 
be  observed  continuously  by  the  visiting  nurses'  association  or  similar 
organizations. 

5.  Discrimination  permitted  between  patients  who  are  best  suited  for 
residence  in  institutions  for  incipient  cases,  detention  resorts,  or  hospitals 
for  hopeless  consumptives.  The  proper  classification  of  these  individ- 
uals and  the  recognition  of  their  pecidiar  needs  and  requirements  rep- 
resents one  of  the  important  functions  of  the  dispensary. 

6.  The  extension  of  material  aid,  when  necessary,  in  the  way  of  gra- 
tuitous advice,  food,  clothing,  medicines,  sputum-cups,  gauze,  disin- 
fectants, etc.,  in  accordance  with  the  manner  outlined  for  the  consump- 
tive at  home. 

7.  The  offering  of  comfort,  reassurance,  and  general  guidance  to 
immediate  relatives  and  friends  upon  matters  pertaining  to  the  general 
subject  of  prevention.  Under  tliis  heading  should  be  included,  when 
suggested  by  the  visiting  nurses,  the  examination,  by  some  mcmlier  of 
the  dispensary  medical  staff,  of  any  member  of  the  famih'  or  others 
with  whom  the  patient  has  been  brought  into  intimate  association. 

In  general,  the  primary  function  of  the  tuberculosis  dispensary  is 
its  position  as  a  basis  for  further  operations.  Without  this  the  house- 
to-house  visitation,  with  supervision  of  the  consumptive  at  home,  is 
entirely  impracticable  in  cities  devoid  of  compulsory  notification  laws. 
Further,  the  proper  selection  of  cases  for  the  various  institutions  for 
consumption  would  be  quite  impossible  without  the  preliminary  direc- 
tion exercised  at  the  dispensary. 

A  valuable  modification  of  the  tuberculosis  free  dispensary  is  found 
in  the  so-called  da;/  resort  or  day  cure.  In  1900  a  plan  was  adopted  in 
Berlin  for  the  establishment  of  day  resorts  for  convalescents  from  various 
hospitals,  of  which  tuberculous  patients  comprised  approximately  one- 
half.  Accommodations  were  secured  in  a  large  open  place,  and  facilities 
afforded  for  patients  to  recline  in  the  open  air  during  pleasant  weather. 
They  were  permitted  to  converse  and  play  games  during  a  portion  of 
the  day,  but  were  compelled  to  rest  at  other  times.  They  were  also 
instructed  with  care  as  to  the  danger  of  transmitting  the  disease  to 


EXTENSION    OF    MATERIAL    AID    ACCORDING    TO    VARYING    NEEDS      585 

Others.  Food  was  served  several  times  during  the  day.  This  system 
of  "  day  cures"  has  been  adopted  in  Germany,  France,  England,  Belgium, 
and  Austria,  and  remarkable  results  are  being  achieved.  A  similar  estab- 
lishment has  been  started  in  Roxbury,  Mass.,  known  as  "The  Parker 
Hill  Sanatorium."  Here  invalids  are  offered  the  benefit  of  pure  air, 
good  food,  and  such  medicine  as  is  needed.  They  are  afforded  an  oppor- 
tunity to  rest  in  reclining  chairs  or  cots,  and  are  comfortably  clothed  and 
housed  during  inclement  weather.  Similar  facilities  are  offered  to  women 
in  Boston  at  the  Samaritan  Hospital  Day  Camp. 

Valuable  as  is  this  modification  of  the  free  dispensary,  the  effective- 
ness of  such  a  scheme  must  be  very  greatly  curtailed  unless  there  be 
instituted  a  system  of  domicUiary  visitation,  precisely  after  the  manner 
of  the  tuberculosis  dispensary.  It  is  this  latter  feature  of  reaching 
the  homes,  where  grossly  unsanitary  conditions  are  found  to  e.xist, 
that  is  productive  of  the  best  results  in  the  effort  toward  prevention. 
The  greatest  degree  of  protection  to  the  public  must  accrue  from  the 
daily  personal  dissemination  of  practical  truths  in  the  very  homes  and 
workshops  of  the  poor,  where  exists  the  most  important  habitat  of  the 
disease.  In  view  of  the  fact  that  indigent  consumptives  are  out  of  all 
proportion  to  the  capacity  of  any  number  of  institutions,  it  is  apparent 
that  the  tuberculosis  movement  should  relate  not  alone  to  providing 
a  temporary  means  of  lodging  for  the  known  victims  of  disease,  but  to 
conducting  a  definite  system  of  defense.  Through  the  influence  of 
kindly  personal  contact  resulting  from  periodic  domiciliary  visits,  the 
propagation  of  knowledge  regarding  the  dangers  of  infection  becomes 
particularly  effective.  It  must  he  remembered  that  it  is  this  educational 
influence  within  a  community  that  reflects  one  of  the  chief  benefits  of 
all  consumptive  institutions  or  agencies.  Those  who  have  profited, 
either  at  home  or  in  sanatoria,  through  the  force  of  example  readily 
become,  in  turn,  self-constituted  apostles  to  spread  broadcast  the  gospel 
to  which  they  have  become  so  much  indebted.  With  a  correct  appreci- 
ation of  the  proper  methods  of  hygienic  living,  the  consumptive  is  enabled 
in  a  practical  way  to  enlighten  those  with  whom  he  may  come  in  con- 
tact, concerning  the  manner  of  restricting  the  transmission  of  the  disease. 

Still  another  modification  of  the  tuberculosis  free  dispensary,  known 
as  The  Tuberculosis  Class  Si/stem,  originating  with  Dr.  Pratt,  and  per- 
fected by  the  assistance  of  Dr.  Hawes,  2d,  of  Boston,  has  been  established. 
It  has  been  the  effort  further  to  elaborate  the  educational  feature  and 
supplement  the  deficiency  in  supervision  and  discipline  which  necessarily 
obtains  where  the  dispensary  methods  alone  prevail.  This  system  is  de- 
signed to  reach  but  comparatively  few  people,  but  to  extend  to  those  the 
maximum  attention.  The  patient  is  admonished  to  lead  a  strictly  out- 
of-door  life,  avoid  work,  and  to  comply  rigidly  with  detailed  instructions. 
The  clinical  history  is  taken,  and  the  lungs  and  sputum  periodically  exam- 
ined. Visits  to  the  home  are  made  by  nurses  or  "friendly  visitors,"  so 
called,  definitely  qualified  to  impart  kindly  words  of  advice  and  yet  to 
exact  obedience.  Facilities  are  found,  if  possible,  for  sleeping  out-of- 
doors,  either  upon  a  balcony  or  upon  the  roof,  protected  by  awnings,  or  in 
tents  upon  the  ground.  Reclining  chairs  are  provided  and  needed  assist- 
ance rendered  in  the  way  of  food  and  clothing,  after  the  manner  inaug- 
urated under  the  auspices  of  charity  organizations  and  visiting  nurse 
associations  in  different  cities. 

Similar  work  may  be  accomplished  in  the  suburbs  of  large  cities, 


586  PROPHYLAXIS,    GEXERAL    AND    SPECIFIC    TREATMENT 

as  is  practised  under  the  supervision  of  the  Social  Service  Bureau  of  the 
Massachusetts  General  Hospital.  Suburban  tuberculosis  classes  are 
formed  to  provide  for  out-of-town  consumptives.  While  the  percentage 
of  cures  has  thus  far  been  very  small,  the  primary  object,  namely,  the 
education  of  the  patient,  has  been  accomplished  in  nearly  all  cases.  An 
element  of  some  importance  in  the  conduction  of  suburban  classes  is 
the  greater  probability  of  arousing  a  local  interest  among  the  suburban 
health  authorities.  An  active  initiati\-e  among  these  officials  to  care 
for  their  own  consumptives  is  a  result  fondly  to  be  desired.  The  class 
system,  though  worthy  of  much  commendation,  appears,  on  account  of 
tile  elaborate  detaO,  to  be  very  limited  in  its  application.  It  would 
almost  seem,  in  the  present  state  of  public  apathy  and  indifference 
in  some  quarters,  with  the  tendency  toward  hysteric  phthisiophobia 
in  others,  that  more  practical  results  along  the  lines  of  prevention 
could  be  secured  by  not  concentrating  the  energies  of  intelligent  workers 
upon  so  comparatively  few  patients.  It  is  probable,  in  the  interests  of 
prophylaxis  alone,  that  the  sphere  of  usefulness  of  the  class  system  in 
some  instances  coidd  be  extended  by  dispensing  with  the  weekh^  meet- 
ings after  a  short  period,  and  thereby  increasing  the  list  of  members  or 
by  the  formation  of  new  classes  from  time  to  time. 


CHAPTER   LXXXM 


THE  DISSEMINATION,  TO  THE  GENERAL  PUBLIC, 
THROUGH  THE  MEDIUM  OF  VARIOUS  CHANNELS, 
OF  AUTHENTIC  OFFICIAL  INFORMATION  REGARDING 
THE  PREVENTION  OF  CONSUMPTION 

Emphasis  has  been  given  to  the  prime  necessity  of  imparting  imme- 
diate instruction  to  the  pulmonary  invalid,  and  of  appealing  in  devious 
ways  to  his  sense  of  obligation,  that  the  rights  of  others  may  be  respected. 
In  the  effort  to  restrict  a  preventable  di.sease  that  destroj'S  annuallj' 
150,000  lives  in  this  country,  especial  importance  also  attaches  to  the 
education  of  the  general  public.  The  ignorance,  apathy,  and  indiffer- 
ence for  a  long  time  exhibited  regarding  a  subject  worthy  of  the  utmost 
concern,  and  the  popular  prejudice  later  entertained,  jointly  suggest  the 
need  of  a  comprehensi\-e  system  of  education  directed  to  all  classes  and 
conditions.  Above  all,  there  is  demanded  an  acceptance  of  rational, 
well-sustained  conceptions  relative  to  the  possil^Uities  of  infection,  and 
the  best  means  of  avoidance.  To  divest  the  pulslic  mind  of  exaggerated 
and  distorted  notions  regarding  certain  supposed  elements  of  danger,  is 
no  less  desirable  than  to  enliuhten  the  masses  reuarding  proper  methods 
of  defense  against  conditions  actually  inimical  to  health. 

The  education  of  the  public  concerning  a  prol>lem  of  such  overwhelm- 
ing importance  can  he  secured  only  by  the  wide-spread  inculcation  of 
practical  knowledge  and  the  convincing  demon.stration  of  actual  facts. 
By  whatever  methods  popular  instruction  is  attempted,  it  is  quite  essen- 
tial that,  for  real  effectiveness,  there  should  be  instituted  a  systematic 
propaganda  of  education.     Lenity  of  purpose  and  harmony  of  action  are 


DISSEMINATION    OF    INFORMATION    REGARDING    PREVENTION         587 

important  considerations,  and  to  tiiis  end  it  is  suggested  tliat  all  local 
effort  should  receive  its  general  direction  and  impetus  from  some  duly 
recognized  and  responsible  source.  The  vital  element  of  success  in  the 
educational  movement  relates  to  the  establishment  of  the  most  com- 
plete confidence  on  the  part  of  the  people  in  the  ability,  sincerity,  and 
executive  capacity  of  those  upon  whom  is  imposed  the  task  of  official 
guidance. 

There  is,  perhaps,  no  better  medium  for  the  dissemination  of 
authentic  data  concerning  consumption  than  the  formation  of  local 
antituberculosis  societies,  acting  in  full  unison  with  municipal  and  State 
health  authorities,  and  in  cooperation  with  a  central  organization  of 
national  scope.  In  this  manner  the  truths  to  be  carried  home  to  each 
individual  will  be  in  nrcmd  with  the  most  modern  scientific  investiga- 
tion, and  will  reflect  upoii  practical  questions  the  consensus  judgment 
of  active,  trained  \\(iikcMs,  whose  lives  have  been  devoted  to  the  study 
of  medical  and  sociologic  conditions.  Practical  instruction  emanating 
from  such  sources,  and  resourcefully  conveyed  to  the  general  public 
through  various  channels,  cannot  fail  to  have  a  most  enlightening  influ- 
ence. 

Local  organizations,  either  charitable  in  character  or  operating 
purely  in  conjunction  with  the  National  Association  for  the  Study 
and  Prevention  of  Tuberculosis,  constitute,  if  efficiently  officered 
and  properly  equipped,  the  most  effective  agencies  under  whose  aus- 
pices may  be  transmitted  trustworthy  data  for  the  information  of  the 
public.  It  should  be  borne  in  mind  that  the  educational  aim  to  be 
accomplished  is  attained,  not  wholly  as  a  result  of  the  organization 
employed  for  this  purpose,  but  rather  by  virtue  of  the  aggressive  initi- 
ative, tactfulness,  and  enthusiastic  devotion  to  duty  ofthe  executive 
officers.  In  this  connection  it  is  not  inappropriate  to  pay  a  tribute  to 
the  indomitable  energy  of  those  who  have  so  cheerfully  and  capably 
discharged  their  official  obligations  during  the  present  national  agita- 
tion regarding  consumption. 

Other  things  being  equal,  the  most  satisfactory  efforts  in  the  way 
of  public  enlightenment  may  be  expected  to  attend  a  plan  of  cam- 
paign formulated  along  the  lines  of  a  national  association  with  subordi- 
nate State  organizations.  Such  a  situation  prevails  in  the  majority  of 
the  States,  or^aiiizcd  \\<iik  liciim'  carried  on  in  close  cooperation  with  the 
National  Associat  inii  Iduiiili'd  in  1904.  It  is  well  worthy  of  comment 
that  in  several  States,  a^suciations  for  the  prevention  and  control  of 
tuberculosis  were  actively  in  operation  long  before  the  National  Asso- 
ciation was  contemplated.  The  first  State  organization  of  this  charac- 
ter was  the  Pennsylvania  Society  for  the  Prevention  of  Tuberculosis, 
which  came  into  existence  in  1892.  Since  then  numerous  State  associ- 
ations have  been  formed,  as  well  as  other  organizations  for  the  control 
of  the  disease.  The  National  Association  for  the  Study  and  Prevention 
of  Tuberculosis  received  its  inspiration  in  1904,  and  its  inception  for 
organized  effort  at  Atlantic  City  in  June  of  the  same  year.  The  first 
annual  meeting  was  held  at  Washington  in  May,  1905,  the  work  being 
divided  into  three  sections,  i.  e.,  the  sociologic,  clinical  and  climato- 
logic,  pathologic  and  bacteriologic.  It  has  been  the  effort  of  this 
body  to  maintain  such  an  organization  as  to  combine  the  more  or  less 
divergent  efforts  of  other  associations  and  of  individual  workers  in  order 
to  conduct,  by  dint  of  united  cooperation,  a  far-reaching  campaign  of 


588  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

education.  Under  the  capable  direction  of  the  executive  secretary, 
Mr.  Livingston  Farrand,  the  practical  work  of  the  association  has  been 
one  of  signal  achievement.  State  associations  now  exist  in  the  following 
States:  New  Hampshire,  Vermont,  Pennsylvania,  New  Jersey,  Delaware, 
Maryland,  North  Carolina,  Georgia,  Ohio,  Indiana,  Kentucky,  Illinois, 
Minnesota,  Iowa,  and  Washington.  Of  these,  eight  have  been  organized 
during  the  past  two  years;  i.  e.,  New  Jersey,  Delaware,  North  Carolina, 
Georgia,  Kentucky,  Minnesota,  Iowa,  and  Washington.  According 
to  the  report  of  the  executive  secretary,  definite  plans  are  completed 
for  organization  of  State  associations  in  Missouri,  Rhode  Island,  Wiscon- 
sin, and  New  York.  The  movement  for  organization  is  well  under  way 
in  Virginia,  Michigan,  California,  Alabama,  Texas,  North  Dakota,  and 
Oregon.  In  Massachusetts  excellent  work  is  being  conducted  under 
the  auspices  of  the  Boston  association,  which  acts  as  a  center  of  operation 
for  the  entire  State. 

Largely  through  the  efforts  of  the  National  Association  an  impetus 
has  been  given  for  organizetl  effort  not  only  in  the  larger  cities  of  the 
country,  but  in  many  of  the  smaller  communities.  Of  the  thirt^'-eight 
cities  in  the  United  States  with  a  population  of  over  100.000,  according 
to  the  census  of  1900,  there  existed,  two  years  ago,  definite  organizations 
for  the  prevention  of  consumption  in  but  fifteen,  i.  e..  New  York, 
Chicago,  Philadelphia,  St.  Louis,  Boston,  Baltimore,  Cleveland,  Buffalo, 
Detroit,  Washington.  Minneapolis.  Rochester.  Worcester.  New  Haven, 
and  Scranton.  Since  the  organization  of  the  society,  effective  as.soci- 
ations  for  the  prevention  of  the  tlisease  have  been  formed  in  Cincinnati, 
Pittsburgh,  New  Orleans,  Newark,  Jersey  City,  Louisville,  Providence, 
Columbus,  Syracuse,  Milwaukee,  and  Patterson,  Twelve  cities  out  of 
the  thirty-eight  have  thus  far  failed  to  complete  definite  organizations 
for  work  along  these  lines,  although  steps  are  now  being  taken  for  this 
purpose  in  St.  Paul,  Toledo,  Los  Angeles,  and  Fall  River.  The  move- 
ment for  the  formation  of  antituberculosis  societies  is  being  agitated  in 
Indianapolis,  Denver,  and  Allegheny,  Effective  work,  however,  has 
been  accomplished  in  Denver  for  some  years  in*  the  ^ledical  Advisory 
Committee  of  the  Charity  Organization  Society.  Up  to  this  time,  San 
Francisco,  Kansas  Cit}-,  St.  Joseph,  Omaha,  and  Memphis  are  reported 
to  be  without  effective  organizations  for  the  prevention  of  tuberculosis. 
In  forty  of  the  smaller  communities  throughout  the  country  a  spirited 
effort  has  been  made  for  the  prevention  of  consumption,  thus  establish- 
ing a  total  number  of  seventy-two  local  organizations  in  correspondence 
with  the  National  Association.  The  movement  for  organizations  is  now 
being  agitated  in  many  other  of  the  smaller  cities. 

An  active  aggressive  campaign  is  being  carried  on  in  Porto  Rico 
upon  the  lines  recommended  by  the  National  Association.  Organized 
work  in  the  form  of  antituberculosis  societies  has  been  carried  on 
effectually  in  other  countries.  In  Great  Britain  the  work  is  per- 
formed systematically  under  the  guidance  of  the  "National  Asso- 
ciation for  the  Prevention  of  Consumption  and  Other  Forms  of  Tuber- 
culosis," with  auxiliary  branches  in  various  parts  of  the  United  Kingdom. 
In  Germany  there  are  in  the  larger  cities  over  120  societies  whose  avowed 
purpose  is  to  combat  tuberculosis.  These  associations  are  closely 
identified  with  a  central  committee  for  the  establishment  of  sana- 
toria, and  are  the  means  of  stimulating  powerfully  the  movement 
toward  prevention.     In  France  about  80  associations  exist  in  various 


DISSEMINATION    OF    INFORMATION    REGARDING    PREVENTION         589 

portions  of  the  Republic,  all  operating  in  unison  with  the  Central  Federa- 
tion, which  enjoys  the  aid  and  patronage  of  the  highest  civic  officials, 
and  the  cooperative  support  of  all  medical  workers.  In  Switzerland 
the  organized  movement  has  been  systematically  conducted  since  1895. 
There  are  antituberculosis  societies  in  17  cantons,  all  established  for 
the  purpose  of  disseminating  popular  education.  A  central  tuberculosis 
association  was  founded  in  1902.  In  Denmark  the  campaign  of  pre- 
vention originated  in  1895  among  the  members  of  the  Danish  Medical 
Association.  While  active  efforts  were  made  toward  the  education  of 
the  masses  and  much  valuable  work  accomplished,  the  "National  Asso- 
ciation for  Combating  Tuberculosis"  was  not  founded  until  1901,  since 
which  time  great  exertions  have  been  made  toward  the  enlightenment 
and  protection  of  the  people.  Organized  movements  are  being  conducted 
with  enthusiasm  in  Italy,  Norway,  Sweden,  Austria,  Spain,  Scotland, 
Russia,  Portugal,  Canada,  Australia,  and  in  several  countries  in  South 
America.  From  the  experience  offered  and  the  results  obtained  the 
world  over  by  virtue  of  effective  organization,  it  is  clearly  demonstrable 
that  successful  organized  endeavor  toward  public  education  must  pro- 
ceed largely  through  the  instrumentality  of  numerous  local  societies,  in 
allegiance  to  a  central  association  endowed  with  supervisory  authority, 
and  cooperating  with  the  movement  in  other  countries  through  the 
influence  of  an  international  association. 

Under  the  direct  and  responsible  direction  of  these  associations 
instruction  may  be  imparted  to  the  people  through  the  medium  of: 
(a)  The  schoolroom;  (b)  publications;  (c)  the  lecture  platform;  (d) 
exhibitions;  (e)  the  family  physician. 

The  Public  Schools. — A  comprehensive  scheme  for  the  education 
of  the  public  should  have  for  its  foundation  the  teaching  of  the  elemen- 
tary principles  of  hygiene  to  the  very  young.  There  are  many  obvious 
difficulties  in  the  way  of  awakening  adults  to  a  realizing  sense  of  the 
enormity  of  the  tuberculosis  problem.  It  is  comparatively  easy, 
however,  to  attract  the  attention  of  children  in  simple  and  ingenious 
ways,  thus  not  only  beginning  their  prophylactic  education  at  an  early 
age,  but  perhaps,  more  important  still,  conveying  information  through 
them  in  a  peculiarly  effective  manner  to  their  parents.  Once  the 
interest  having  been  thoroughly  aroused  in  the  schoolroom  by  the  use 
of  drawings,  colored  illustrations,  elementary  text-books,  and  enter- 
taining talks,  the  child  is  wont  to  carry  home  a  wondrous  recital  of 
the  hygienic  lesson.  The  attention  of  the  family  thus  irresistibly 
attracted  to  a  subject  replete  with  human  interest,  is  further  stimulated 
by  the  receipt  of  supplementary  circular  information,  which  each  child 
should  be  instructed  to  deliver  to  the  parents. 

It  is  esfsential  that  the  instruction  received  at  school  should  be  com- 
pulsory, and  that  it  should  be  imparted  under  the  supervision  and  with 
the  indorsement  of  duly  constituted  medical  and  educational  authorities. 
Text-books  and  educational  pamphlets  should  be  prepared  with  the 
utmost  care,  especial  effort  being  made  to  insure  simplicity  of  style  and 
attractiveness  of  presentation.  These  considerations  apply  with  equal 
force  to  oral  methods  of  instruction,  the  prime  desideratum  being  an 
intelligent  understanding  of  a  few  elementary  principles,  rather  than 
the  effort  to  memorize  a  tedious  list  of  precautionary  rules.  The 
instruction  in  schools  should  be  undertaken  at  first  by  medical  men 
of  especial  fitness  and  adaptability,  but  the  work  may  later  be  dele- 


590  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

gated  to  teachers  previously  trained  in  hygienic  science.  The  mere 
perusal  of  illustrated  text-books,  no  matter  how  attractive  in  design, 
is  quite  insufficient  for  the  satisfactory  elaboration  of  fundamental 
propositions  in  connection  with  consumption.  It  is  desirable  that 
all  abstract  statements  be  properly  interpreted  and  fully  expounded 
in  their  practical  application  by  competent  instructors. 

The  efforts  of  children  in  the  warfare  against  consumption  may  be 
enlisted  actively  or  not  at  all,  according  to  the  manner  of  their  instruc- 
tion. The  distribution  of  leaflets  and  the  learning  by  rote  of  printed 
matter  containing  certain  negative  pronunciamentos  are  far  less  effec- 
tive as  a  measure  of  prophylaxis  and  education  than  verbal  atlmonitions. 
The  submission  to  school-children  of  a  long  list  of  printed  rules  to  be 
committed  to  memory  in  the  hope  of  their  actual  observance  is  not 
inspired  by  a  realizing  sense  either  of  the  practical  sources  of  danger  or 
of  the  most  effective  means  to  secure  the  cooperation  of  the  young. 
No  chsparagement  is  intended  of  the  excellent  instructions  given  to 
children  in  the  interests  of  personal  cleanliness,  nor  of  their  transmission 
in  printed  form  to  adults.  It  is  contended  simply  that  children  should 
live  as  children,  and  not  until  they  become  of  more  mature  age  should 
they  be  expected  to  put  awaj^  the  inherent  ways  of  childhood  and 
become  amenable  to  the  influence  of  printed  regulations.  When  it 
shall  be  brought  to  pass  that  little  ones  have  become  so  impregnated 
with  the  spirit  of  prevention  as,  in  conformity  with  printed  rules,  to 
refrain  from  spitting  upon  playgrounds,  but  only  upon  bits  of  cheese- 
cloth to  be  placed  in  a  suitable  repository  before  being  burned,  to  wash 
their  fruit  before  eating  it,  to  give  up  whistles,  trumpets,  bean-blowers, 
apple-cores,  to  wash  their  hands  and  clean  their  nails  before  putting 
food  in  their  mouths,  and  to  resort  solely  to  individual  drinking-cups 
at  school,  then,  indeed,  will  the  millenium  of  prophylaxis  be  reached. 
While  not  the  slightest  abatement  of  rational  methods  in  the  edu- 
cation of  the  young  should  be  countenanced,  it  is  believed  that  the 
more  practical  results  of  instruction  imparted  in  the  schoolroom  will 
be  exhibited  in  the  transmission  of  this  knowledge  to  the  home, 
and  its  subsequent  application  to  the  prevention  of  house  infection.  It 
is  not  likely  that  the  curtailment  of  the  disease  will  be  effected,  to  a 
material  extent,  through  the  development  of  radical  innovations  per- 
taining to  the  instinctive  personal  habits  of  children. 

Publications. — A  most  important  feature  of  a  systematic  educa- 
tional propaganda  consists  of  the  wide-spread  dissemination  of  authentic 
printed  information,  issued  in  various  forms  under  the  sanction  and 
authority  of  antituberculosis  societies  or  other  equall.y  responsilile 
sources.  The  information  for  the  general  public  should  be  essentially 
reassuring,  if  not  optimistic  in  character,  though  by  no  means  mini- 
mizing the  known  dangers  of  infection  under  unfavorable  conilitions. 
In  view  of  the  frequent  unreasoning  fear  and  the  somewhat  intolerant 
public  sentiment  relative  to  contact  with  pulmonary  invalids,  it  is  par- 
ticularly desirable  that  association  with  conscientious  ami  ilcaiil\-  mn- 
sumptives  should  be  empha.sized  as  entirely  innocuous,  and  that  cdutact 
with  the  careless  or  vicious,  indicated  as  the  chief  source  of  danger.  It 
should  be  made  perfectly  clear  that  the  campaign  of  prevention  relates 
to  the  disease  itself  and  the  conditions  responsible  for  its  development, 
rather  than  to  the  unfortunate  people  .suffering  from  the  tuberculous 
infection. 


DISSEMINATION    OF    INFORMATION    REGARDING    PREVENTION        591 

The  detailed  information  with  which  the  public  should  be  sup- 
plied through  various  channels  will  be  presently  reviewed,  but  of  more 
immediate  interest  is  a  consideration  of  the  most  effective  manner 
in  which  to  distribute  the  educational  literature.  It  is  readily  apparent 
that  recourse  should  be  taken  to  all  available  avenues  of  reaching  the 
public  eye — circular  distribution,  reprints,  magazine  articles,  and  news- 
papers. It  is  also  evident  that  an  effort  should  be  made  to  bring 
suitable  reading  matter  of  this  nature  before  all  classes  and  nationalities. 
The  subject  material  and  the  form  of  presentation  must  needs  vary 
within  wide  limits  in  accordance  with  the  intelligence  and  sphere  of  life 
of  those  to  whom  the  literature  is  addressed. 

While  much  of  value  has  been  accomplished  as  a  result  of  the  cir- 
culars issued  from  time  to  time  by  various  health  authorities  and  anti- 
tuberculosis societies,  the  fact  remains  that  the  field  has  been  insuf- 
ficiently canvassed.  Some  of  the  current  popular  magazines  have 
contained  valuable  articles  written  by  laymen  offering  suggestions  in  the 
way  of  prevention  or  treatment.  Other  periocUcals  have  been  greatly 
enhanced  in  usefulness  by  able  contributions  from  physicians  endowed 
with  a  sense  of  sociologic  obligations.  The  great  mass  of  the  people, 
however,  have  not  been  enabled  to  profit  to  the  fullest  extent  from 
the  modern  attitude  of  the  profession  regarding  the  possibilities  of 
prevention.  Ethical  scruples  have  been  entertained  by  medical  men 
as  a  class  against  permitting  their  publications  to  appear  in  other 
than  strictly  professional  journals,  and  the  public,  to  a  large  extent, 
has  been  denied  the  privilege  of  perusing  the  contributions  and  dis- 
cussions of  learned  observers  upon  practical  questions.  As  a  result, 
numerous  articles  of  absorbing  human  interest  are  buried  in  the 
public  transactions  of  medical  societies  or  submitted  through  the 
agency  of  medical  journals  only  to  the  inspection  of  members  of  the 
profession.  Popular  monthly  magazines,  current  weeklies,  and  daily 
newspapers,  all  of  which  would  eagerly  grasp  at  authentic  reading 
matter  bearing  upon  the  subject  of  the  hour,  are  not  permitted,  through 
the  innate  modesty  of  the  profession,  to  fill  their  columns  with  educa- 
tional data  compiled  by  medical  men  of  recognized  eminence.  If  it  is 
really  important  to  convey  reliable  and  complete  information  to  the 
masses  regarding  the  communicability  of  consumption  and  the  methods 
to  prevent  its  spread,  there  can  be  no  excuse  for  failure  to  utilize,  under 
the  jurisdiction  of  antituberculosis  societies,  the  public  press,  no  mat- 
ter in  other  respects  how  sen.sational  may  be  its  tone,  insincere  its 
motives,  or  superficial  its  character.  Articles  printed  under  the  sanction 
and  at  the  request  of  regularly  constituted  executive  officers  of  tuber- 
culosis committees  and  antituberculosis  organizations,  need  not  reflect 
in  the  slightest  upon  the  ideals  of  the  contributors.  It  is  important 
that  such  articles  be  made  a  conspicuous  feature  and  appear  at  periodic 
intervals.  They  should  be  written  entirely  by  incUviduals  especially 
fitted  for  this  work,  to  which  they  have  been  assigned  by  responsible 
officials  in  the  organized  campaign  of  education. 

To  those  interested  in  the  more  scientific  aspects  of  the  tuberculosis 
problem,  opportunity  should  be  afforded  for  securing  copies  of  the 
transactions  of  the  National  or  State  associations  for  the  prevention 
of  the  disease.  There  should  be  published  occasionally,  in  the  popular 
magazines,  or  newspapers,  a  list  of  the  more  recent  or  important  con- 
tributions upon  technical  phases  of  the  subject,  and  information  given 


592  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

as  to  where  and  how  reprints  may  be  obtained.  These  should  be 
provided  through  the  instrumentality  of  antituberculosis  societies  at 
a  nominal  cost.  The  public  should  be  solicited  to  subscribe  for  the 
official  organ  of  the  National  Association  for  the  Prevention  of  Con- 
sumption, "Outdoor  Life,"  which  in  turn  should  devote  its  columns 
almost  exclusively  to  the  education  of  the  people  upon  practical  prob- 
lems pertaining  to  the  control  and  suppression  of  the  disease. 

Effort  should  be  made  to  enlist  the  cooperation  of  publications  uphold- 
ing the  cause  of  labor,  in  order  that  the  institution  of  rational  measures 
to  restrict  the  development  of  consumption  among  the  masses,  rather 
than  a  strife  for  shorter  hours,  be  made  the  bone  of  contention  of  trades 
unions.  The  same  is  true  of  the  many  journals  devoted  to  the  interests 
of  the  numerous  secret  and  fraternal  organizations,  the  watchwords  of 
cleanliness,  protection,  and  disinfection  being  much  more  appropriate, 
from  a  practical  standpoint,  than  faith,  love,  hope,  charity,  etc. 

Lectures. — Generally  speaking,  more  difficulty  must  be  e.xperienced 
in  reaching  the  public  through  the  lecture  platform  than  from  the  public 
press.  Further,  the  number  of  individuals  influenced  directly  through 
this  means  is  necessarily  small.  The  gi-eat  mass  of  the  people  are  not 
sufficiently  awake  to  the  gravity  of  the  situation  to  feel  particularly 
attracted  by  the  anticipation  of  an  evening  devoted  to  the  elucidation 
of  tubercidosis  problems,  no  matter  how  ably  or  ingeniously  the  subject 
is  presented.  The  several  organizations  under  whose  auspices  lectures 
may  be  given  are  capable,  as  a  rule,  of  securmg  but  a  comparatively 
small  attendance,  and  this  composed  of  inchviduals  already  interested 
more  or  less  in  sociologic  matters.  The  audiences  are  composed  mostly  of 
members  of  women's  clubs,  young  men's  Christian  associations,  churches, 
fraternal  organizations,  and  of  school-teachers'  societies.  The  very 
class  whom  it  is  most  essential  to  attract  to  such  gatherings,  i.  e.,  the 
working  people,  the  wage-earners,  operatives,  occupants  of  tenement 
houses  and  of  unhygienic  apartments,  are  rarely  present.  It  follows 
that,  for  practical  far-reaching  purposes,  the  beneficent  educational 
influence  of  such  lectures  may  be  obtained  more  from  their  publication 
in  full  with  the  accompanying  editorial  comment  than  from  the  dis- 
course itself. 

To  be  particularly  effective,  lectures  must  be  given  in  serial  form 
at  rather  short  intervals,  and  embodying  different  phases  of  the  tuber- 
culosis question,  and  adapted  to  audiences  of  varying  character.  They 
should  be  suitably  illustrated  by  drawings  or  stereoptical  pictures,  and 
the  subject  matter  interspersed  with  pertinent  or  amusing  anecdotes  to 
furnish  a  justifiable  degree  of  entertainment,  and  maintain  a  lively  inter- 
est in  the  more  important  details.  Lecturers  in  every  way  qualified 
to  furnish  enlightenment  and  entertainment  are  exceedingly  difficult 
to  obtain,  and  thus  another  difficultj'  is  encountered  in  a  successful 
application  of  this  method  of  educational  work.  It  should  be  utilized, 
however,  in  all  localities,  when  rendered  possible  by  the  willing  coopera- 
tion of  earnest  and  competent  workers. 

Exhibitions. — A  novel  and  singularly  attractive  manner  of  pre- 
senting tuberculosis  truths  to  the  general  public  has  been  found  through 
the  agency  of  tuberculosis  exhibitions.  This  method,  originally  adopted 
in  order  to  bring  important  data  forcibly  before  the  eye,  has  already 
carried  conviction  to  a  vast  number  of  people.  The  first  exhibition 
was  held  in  New  York  under  the  auspices  of  the  National  Association 


DISSEMINATION    OF    INFORMATION    REGARDING    PREVENTION        593 

for  the  Prevention  of  Tuberculosis  and  the  local  committee  of  the 
New  York  Charity  Organization  Society.  The  communicability, 
preventability,  and  curability  of  consumption  were  demonstrated  by 
diagrams,  charts,  models,  photographs,  pathologic  specimens,  and  lan- 
tern slides  in  connection  with  lectures.  The  exhibit  operated  in  con- 
nection with  the  National  Association,  was  inaugurated  November,  1905, 
and  has  proved  a  remarkably  efficient  means  of  promoting  the  education 
of  the  public.  The  attendance  has  been  most  gratifying,  over  200,000 
viewing  the  exhibition  during  the  first  six  months  of  its  operation  to 
May,  1906.  During  the  following  year  the  attendance  was  167,981, 
making  a  total  of  372,000.  The  executive  secretary  reports  that  from 
June,  1906,  to  April,  1907,  it  was  shown  in  the  following  eleven  cities: 

Attendance 

Grand  Rapids,  Mich 12,000 

Manistee,  Mich 3,200 

Detroit,  Mich 6,400 

Toronto,  Canada 12,969 

Cleveland,  Oliio 15,000 

Cincinnati,  Ohio 38,000 

Mexico  City 3,017 

San  Antonio.  Texas 8,000 

Minneapohs,  Minn 17,225 

St.  Paul,  Minn 16,170 

Providence,  R.  1 36,000 

Numerous  local  exhibitions  are  now  being  presented  in  New  York, 
Boston,  New  Jersey,  Illinois,  Toronto,  Rhode  Island,  Maryland, 
Washington,  D.  C,  and  the  State  of  Washington,  under  the  authority 
of  State  or  local  associations.  From  the  interest  already  shown  in  these 
exhibitions,  it  cannot  be  questioned  that  they  constitute  a  wonderfully 
effective  means  of  enlightening  the  masses  regarding  the  dangers  of 
infection  and  the  means  of  prevention.  Their  practical  value  is  greatly 
enhanced  by  judicious  advertising.  In  fact,  it  is  doubtful  if,  without 
a  vigorous  new.spaper  and  circular  campaign,  public  interest  could 
have  been  aroused  to  so  gratifying  a  degree.  Thus,  in  effect  the 
exhibition  combines  the  publication  of  educational  literature,  the 
delivery  of  lectures,  .simple  talks  to  children,  and  the  actual  visual 
demonstration  of  vital  data. 

The  Family  Physician. — The  personal  interpretation  of  important 
educational  matter  constitutes  one  of  the  most  essential  features  in 
the  campaign  against  tuberculosis.  In  no  manner  can  the  interesting 
truths  pertaining  to  the  prevention  of  consumption  be  brought  home 
to  families  and  individuals  so  completely  as  through  the  agency  of  the 
attending  physician.  Through  the  influence  of  the  spoken  word  and 
the  force  of  personal  example,  the  hygienic  lessons  are  diffused  through 
the  community  much  more  effectively  than  from  volumes  of  printed 
matter,  exhibitions,  or  lectures. 

Notwithstanding  a  masterly  manner  of  presentation  of  the  educa- 
tional data  in  various  forms,  and  the  convincing  demonstration  of  the 
advantages  and  necessities  of  rational  prophylaxis,  individuals  often 
refuse  to  accept  the  logic  of  facts  and  refer  vital  considerations  of  this 
nature  to  the  family  physician  for  a  final  decision.  Influential  results, 
therefore,  in  the  warfare  against  the  transmission  of  the  disease,  are 
largely  dependent  upon  the  ability  and  conscientious  devotion  of  the 


594  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

physician,  both  in  the  exercise  of  his  strictly  professional  duties  and  in 
the  sphere  of  social  life.  Were  all  physicians  actively  and  intelligently 
enlisted  in  the  cause  of  prevention,  the  educational  warfare  could  be 
carried  directly  and  irresistibly  to  all  the  homes  and  workshops  which 
may  be  described  as  the  very  heart  of  the  enemies'  country.  Unfortu- 
nately, the  commercial  aspects  of  medical  practice  are  permitted  in  some 
instances  to  assume  such  prominence  among  busy  practitioners  as  to 
stifle  natural  humanitarian  instincts. 

The  proper  expounding  of  the  doctrines  of  prevention  not  infre- 
quently falls  entirely  upon  the  attending  physician,  who  in  a  few 
concise  words,  e\'incing  a  profound  personal  interest,  may  wdeld  a 
tremendous  influence  for  good  among  his  immediate  clientele.  The 
attitude  of  any  physician  in  regard  to  the  principles  and  practice 
of  preventive  medicine  is  usually  more  or  less  familiar  to  the  general 
public,  particularly  in  the  smaller  tov\'ns,  and  the  influence  upon  the 
community  of  his  acceptance  or  repudiation  of  sanitary  and  hygienic 
measure's  is,  indeed,  far  reaching.  The  practical  effects  of  the  present 
effort  toward  the  education  of  the  public  are  rendered  almost  nugatory 
in  some  cases  through  the  stupidity  of  irresponsible  physicians.  A  few, 
even  when  appealed  to  for  a  practical  interpretation  of  educational 
data,  have  been  known  to  remain  so  utterly  indifferent  to  their  obliga- 
tions as  to  disclaim  their  value  or  to  condemn  with  faint  praise. 

It  is  well  known  that  one  of  the  most  essential  requisites  for  a 
successful  campaign  against  consumption  is  an  early  recognition  of  the 
disease.  Deplorable  as  it  may  seem,  the  fact  remains  that,  in  a  very  con- 
siderable proportion  of  cases,  the  nature  of  the  affection  is  not  detected 
by  the  attending  physician  until  long  after  active  destructive  change 
has  taken  place,  greatly  impairing  the  prospects  of  recovery  and  in- 
creasing many  fold  the  dangers  of  conve\-ing  the  infection  to  others. 
It  must  be  admitted  that  in  the  majority  of  cases  the  available  evidence 
is  ample  to  furnUth  an  earli/  diagnosis,  which,  if  made,  would  enhance 
beyond  description  the  chance  of  restoration  to  health,  and  minimize 
the  possibilities  of  further  transmission.  It  is  of  but  little  avail  to 
awaken  public  interest  in  a  great  educational  movement,  to  enact  laws 
pertaining  to  the  administrative  control  of  tuberculosis,  to  erect  dis- 
pensaries, sanatoria,  and  hospitals,  if  the  family  physician  is  to  con- 
tinue in  the  making  of  delayed  and  erroneous  diagnoses.  It  almost 
appears  that  it  is  not  so  much  the  public  that  needs  to  be  educated 
concerning  the  sociologic  features  of  tuberculosis,  as  it  is  the  rank 
and  file  of  the  medical  profession  relative  to  the  detection  of  the  disease 
in  its  incipiency.  Failure  to  appreciate  the  significance  of  rational 
symptoms,  to  conduct  a  thorough  physical  examination,  to  recognize 
the  physical  signs  and  properly  interpret  their  import,  represents  one 
of  the  very  greatest  weaknesses  in  the  defense  now  l^eing  presented 
against  the  spread  of  the  disease.  The  education  of  the  public  through 
the  family  physician  by  word  of  mouth  should  l:)egin  with  the  education 
of  the  physician  himself  in  order  that  he  become  fitted  to  render  truly 
effective  aid.  It  is  undeniable  that  he  may  exert  a  powerful  influence 
for  good  or  evil  in  his  purely  professional  capacity.  It  is  the  man 
behind  the  stethoscope  who  too  often  adds  materially  to  the  pathos  of 
existence  of  pulmonary  invalids  and  their  unfortunate  families.  Upon 
the  other  hand,  the  sphere  of  usefulness  of  the  enlightened  and  con- 
scientious physician  is  almost  unlimited  in  its  application  to  the  cause 


WHAT    THE    PUBLIC    SHOULD    KNOW  595 

of  prevention.  Upon  him  is  bestowed  the  privilege  of  the  prompt 
recognition  of  incipient  tuberculosis,  the  detection  of  unhygienic  con- 
ditions, the  supervisory  control  of  the  invalid,  the  protection  of  the 
family  and  society,  and  the  inculcation  of  just  conceptions  as  to  the 
communicability  and  preventability  of  the  disease. 


CHAPTER  LXXXVII 
WHAT  THE  PUBLIC  SHOULD  KNOW 

In  preceding  pages  it  has  been  stated  that  the  information  to  be 
conveyed  to  the  public,  while  pertaining  to  the  possibilities  of  infection 
and  the  importance  of  prevention,  yet  should  be  essentially  reassuring 
in  nature.  It  is  quite  unnecessary  to  add  to  the  burden  of  the  con- 
sumptive by  increasing  the  humiliation  already  suffered  by  reason  of 
popular  intolerance.  It  is  important,  therefore,  to  remove,  as  far  as 
possible,  exaggerated  fears  relative  to  the  dangers  of  infection,  provided 
precautionary  rules  are  observed.  Upon  the  other  hand,  the  public 
must  be  made  to  entertain  just  conceptions  of  the  actual  menace  to 
life  and  health  resulting  from  an  improper  hygiene,  and  in  consequence 
be  stimulated  to  brook  no  infringement  of  sanitary  laws  by  ignorant 
offenders. 

Attention  has  been  called  repeatedly  to  the  importance  of  a  proper 
disposal  of  the  .sputum,  to  the  necessity  of  absolute  cleanliness  on  the 
part  of  the  consumptive  and  those  about  him,  to  the  care  of  the 
person  and  clothing  of  the  invalid,  to  the  importance  of  fresh  air, 
proper  ventilation  and  sunlight,  and  the  avoidance  of  certain  unfavor- 
able occupations.  Matters  pertaining  to  the  control  of  food-supplies, 
proprietary  medicines,  supervision  of  factories,  department  stores, 
workshops,  mills,  public  buildings,  public  conveyances,  penal  institu- 
tions, churches,  etc.,  will  be  presently  considered  in  connection  with 
The  Administrative  Control  of  all  Important  Factors  Entering  into 
the  Problem  of  Etiology  and  Prophylaxis.  Attention  is  now  directed 
to  the  application,  to  every-day  life,  of  some  of  the  general  principles 
of  prophylaxis  already  enumerated. 

In  view  of  the  prevalence  and  fatality  of  tuberculosis  in  early  years, 
it  is  important  that  the  education  of  the  public  concerning  rational 
prophylaxis  should  begin  with  wise  coun.sels  and  admonitions  regarding 
the  non-procreation  of  predisposed  infants.  Wliile  it  is  perfectly  simple  to 
assert,  from  a  theoretic  point  of  view,  that  the  tuberculous  should  not  be 
permitted  to  marry,  the  situation  is  entirely  different  when  regarded  from 
a  practical  standpoint.  The  marriage  of  tuberculous  individuals  is  by  no 
means  easy  of  prevention.  Many  assume  the  matrimonial  obliga- 
tions without  entertaining  the  remotest  idea  of  their  condition,  while 
in  others  the  first  manifestations  of  a  disease  previously  latent  appear 
some  months  after  marriage,  or  immediately  following  parturition. 
The  sweeping  prohibition  of  marriage  for  consumptives  as  a  class  must 
be  regarded  at  present  as  both  impracticable  and  unwarranted.  A 
problem  so  delicate  can  never  be  fairly  adjusted  by  recourse  to  arbitrary 


59b  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

legal  enactments,  based  upon  the  medical  principles  of  marriage  selection 
and  the  social  aspect  of  procreation.  More  properly  is  it  within  the 
pro\ince  of  the  physician  in  his  professional  capacity  to  exert  such  an 
influence  as  may  be  indicated  in  his  own  judgment  according  to  the 
individual  circumstances. 

It  is  important  for  the  public  to  be  taught  that  the  existence  of 
tubercidosis  should  preclude  marriage  until  the  disease  has  become 
entirely  arrested,  and  then,  as  a  rule,  only  after  the  lapse  of  one  or  two 
years.  In  exceptional  instances  of  partial  arrest  it  may  be  permitted 
after  a  prolonged  period  of  non-recurring  tuberculous  activity.  Even 
under  these  conditions,  particularly  if  the  ivife  has  been  tuberculous, 
procreation  should  be  avoided  unless  the  general  condition,  social  en\d- 
ronment,  and  financial  status  are  exceptionally  good.  The  prognostic 
aspects  of  pregnancy  huve  been  considered  in  connection  with  the  Non- 
tubercidous  Complications.  To  prevent  the  birth  of  prechsposed  chil- 
dren, which  is  the  excuse  sometimes  offered  b}'  practitioners  endowed 
with  a  flexible  conscience,  in  extenuation  of  the  induction  of  prema- 
ture labor  among  tuberculous  women,  is  utterly  without  justification. 
That  such  practice  has  been  indulged  in  by  quasi-reputable  physicians 
solely  upon  the  basis  of  tuberculosis  in  the  male  parent  is  almost 
beyond  belief.  It  is  almost  unnecessary  to  state  that  abortions  are 
devoid  of  cruninalitij  onlji  in  those  cases  in  which  the  judgment  of  two 
or  more  reputable  practitioners  indicates  that  the  life  of  the  mother  is 
to  be  saved  by  such  procedure.  Recoui-se  to  the  evacuation  of  the 
uterus  under  other  circumstances  is  worthy  of  the  most  severe  con- 
demnation and  punishment.  The  same  principles  apply  with  equal 
force  to  the  attitude  of  the  husband  and  wife.  Deplorable  as  is  the 
procreation  of  weakly  children  by  tuberculous  incUviduals,  the  respon- 
sibility of  the  parents  as  to  the  future  course  abruptlj'  ceases  once 
conception  has  taken  place.  Thereafter,  the  decision  as  to  a  possible 
interference  with  gestation  should  be  passed  without  hesitation  to 
the  conscientious  physician,  whose  action  must  be  based  entirely  upon 
the  vital  interests  of  the  mother  without  regard  to  the  character  of 
the  progeny. 

With  the  birth  of  a  child  to  a  tuberculous  mother  the  dangers  of 
postnatal  infection  to  an  infant  already  predisposed,  are  exceeding!}^  great. 
Under  no  circumstances  should  the  mother  be  permitted  to  nurse 
the  infant,  although  not  solely  on  account  of  the  possil)le  contamination 
of  the  milk  bj-  tubercle  bacilli,  iluch  greater  danger  accrues  from 
the  ingestion  of  food  insufficient  in  quantity  and  ill  adapted  in  quality 
to  meet  the  demands  of  a  growing  child.  Another  important  objection 
relates  to  the  added  drain  upon  the  resources  of  the  mother  and  the 
consequent  impairment  of  her  resistance  to  the  tuberculous  process. 

The  next  consideration  of  importance  relates  to  the  character  of 
the  food  to  be  substituted  for  human  milk.  While  the  employment 
of  properly  selected  wet-nurses  has  its  manifest  ad\'antages,  this  means 
of  pro\ading  nourishment  to  infants  is  veiy  limited  in  its  application. 
It  is  necessary,  therefore,  that  the  masses  be  suitably  instructed  con- 
cerning a  few  important  features  pertaining  to  infant  feeding.  It  is 
perhaps  still  more  desirable  that  the  family  physician  should  devote 
an  interested  attention  to  the  nature  and  manner  of  preparation 
of  infant  foods.  All  possible  protection  from  tuberculosis  must  be 
accorded  to  the  little  ones  in  supposedly  healthy  families  as  well  as 


WHAT    THE    PUBLIC    SHOULD    KNOW  Oyi 

in  those  known  to  contain  a  pulmonary  invalid.  The  development  of 
tuberculosis  at  a  very  early  age  occurs  not  only  from  exposure  to 
microorganisms  in  the  household,  but  from  increased  susceptibiliti/  to 
infection  through  impaired  nutrition.  It  thus  follows  that  the  selection 
and  preparation  of  a  food  perfectly  adapted  to  the  sustenance  of  the 
child  constitute  a  vital  factor  in  the  warfare  against  tuberculosis  in 
the  very  young.  This  is  of  infinitely  greater  importance  from  a  practical 
standpoint  than  the  employment  of  measures  looking  toward  the 
avoidance  of  milk  contamination  with  bovine  bacilli.  It  has  been 
demonstrated  clinically  and  i):i,th(i!ogically,  as  explained  in  previous 
pages,  that  tuberculous  lesions  iii:i\-  he  produced  by  the  ingestion  of 
bacilli  in  the  milk  of  tuberculous  cows,  particularly  those  with  infected 
udders.  Instances  of  the  transmission  of  the  disease  in  this  manner, 
though  comparatively  few,  are  still  sufficient  to  demand  a  strict  enforce- 
ment of  laws  governing  the  inspection  of  cattle  and  of  other  precautions, 
as  will  be  described,  to  avoid  bovine  infection.  While  no  relaxation  of 
efforts  in  this  direction  should  be  permitted,  it  is  undoubtedly  true 
that  more  real  danger  to  infants  results  from  ignorance  in  the  selection 
of  artificial  foods,  carelessness  in  their  preparation,  and  irregularities 
of  feeding.  A  discussion  at  this  time  of  the  general  principles  pertaining 
to  "  percentage  feeding  "  for  infants  is,  of  course,  entirely  out  of  place,  but 
a  protest  against  the  indiscriminate  unthinking  selection  of  food  for  the 
very  young  seems  pertinent  in  view  of  the  disproportionate  interest 
of  the  public  regarding  tuberculosis  in  cattle,  the  time,  enei'gy,  and 
money  expended  in  the  preservation  of  hcids,  and  I  lie  tendency  of  many 
phthisiosociologists  to  ascribe  to  milk  inlnt  ion  mi  undue  prominence 
in  the  development  of  tuberculosis.  It  iii:i\'  l>c  stated  parenthetically 
that  some  information  has  been  presented  which  casts  much  doubt 
upon  the  every-day  role  of  milk  as  the  carrier  of  tuberculous  infection 
to  children.  Upon  the  other  hand,  there  can  be  no  question  that  the 
health  of  little  ones  is  seriously  impaired  by  gross  inattention  to  diet. 

Aside  from  the  improper  preparation  of  food,  a  menace  to  the  young 
is  found  in  the  frequent  contamination  of  milk  as  a  result  of  the  presence 
of  nearly  all  forms  of  bacteria.  It  is  true  that  the  vitality  of  these 
germs  may  be  destroyed  by  boiling  or  effective  pasteurization,  but  such 
measures  are  not  universally  employed.  Furthermore,  little  satisfaction 
may  be  derived  from  the  thought  of  ingesting  with  the  milk  the  filth 
products  of  the  dairy,  no  matter  how  thorough  the  pasteurization. 
Sterilized  animal  feces,  though  perhaps  less  objectionable  than  the 
unsterilized,  are  hardly  to  be  considered  a  desirable  constituent  of 
milk  for  commercial  purposes,  yet  it  has  been  found  by  actual  analysis, 
that  a  large  proportion  of  the  milk  sold  in  large  cities  contains  all 
manner  of  contamination  derived  from  uncleanly  dairies.  Absolute 
cleanliness  of  the  stables,  of  the  animals  themselves,  and  of  the  recep- 
tacles for  transportation  is  assuredly  a  factor  of  the  utmost  moment, 
concerning  the  importance  of  which  the  public  should  be  appraised. 
Supplementary  to  this  knowledge  regarding  the  prime  necessity  of 
purity  of  milk-supply,  there  should  be  generally  diffused  instructions 
as  to  the  proper  pasteurization,  in  case  doubt  may  be  entertained  re- 
garding the  observance  of  proper  antecedent  precautions. 

Another  consideration  of  especial  importance  in  the  effort  to  protect 
infants  from  tuberculous  infection  is  the  avoidance  of  proximiti/  to  a 
consumptive  within   the   household.     The   safest   coui'se   to   pursue   is 


598  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 

undoubtedly  the  complete  removal  of  the  invalid  or  the  child  from  the 
dwelling.  This  seldom  being  practicable,  recourse  must  be  taken  to 
measures  insuring  the  greatest  degree  of  isolation  of  the  pulmonary 
invalid,  immediate  contact  with  the  infant  under  no  circumstances 
being  permitted.  When  possible,  a  separate  portion  of  the  house  and 
a  private  porch  should  be  set  aside  for  the  exclusive  use  of  the  con- 
sumptive. The  care  of  the  child  should  be  given  to  a  person  known 
to  be  free  from  infection,  not  even  the  mother,  if  tuberculous,  being 
allowed  to  fondle  or  caress  the  infant.  Kissing  upon  the  mouth 
by  any  one  should  be  absolutely  prohibited.  The  child  should  be 
brought  but  infrequently  into  the  room  of  the  consumptive  mother 
and  should  remain  only  a  short  time.  The  infant  should  not  be 
placed  upon  the  bed  of  the  invalid,  nor  allowed  to  play  upon  the 
floor  of  the  room  wherein  the  patient  is  confined.  Scrupulous  care 
must  be  observed  with  reference  to  the  cleanliness  of  the  hands  and 
person  of  the  consumptive,  as  well  as  the  clothing  and  bedding,  which 
must  be  laundered  separately  from  the  family  linen  in  accordance  with 
instructions  already  prescribed. 

The  precautions  laid  down  relative  to  the  arrest  of  possible  droplet 
infection,  through  the  use  of  gauze  or  cheese-cloth  held  before  the  face 
in  the  act  of  coughing,  should  be  enforced  most  rigidly  when  young  chil- 
dren remain  in  the  same  house.  This  is  particularly  necessary  on  account 
of  the  gravitation  of  bacilli  to  the  carpet  or  rugs  and  the  prevalent  cus- 
tom, among  nurses  and  attendants,  of  leaving  the  little  ones  to  amuse 
themselves  upon  the  floor.  With  proper  precautions  against  the  distri- 
bution of  bacilli  throughout  the  room,  the  habits  of  chUdi'en  in  putting 
miscellaneous  articles  in  the  mouth  are  attended  with  much  less  danger 
of  infection.  Despite  the  observance  of  strict  hygienic  measures  on 
the  part  of  the  invalid,  the  instinctive  practice  among  infants  of  con- 
veying to  the  mouth  almost  everything  that  their  hands  can  touch, 
remains  a  source  of  possible  danger,  and  should  be  prevented  in  very 
early  life  by  the  watchfulness  of  the  nurse  and  in  later  months  by  ad- 
monitory talks.  Especial  pains  should  be  taken  in  the  modern  manner 
of  dusting  and  sweeping,  while  the  ventilation  and  sunning  of  rooms 
should  be  made  as  complete  as  possible.  The  sputum  must  be  disposed 
of  in  accordance  with  directions  previously  described,  and.  in  short,  all 
directions  addressed  to  the  invalid  must  be  obeyed  more  conscientiously 
than  if  the  dwelling  be  occupied  solely  by  adults.  Even  with  the  strict 
enforcement  of  all  precautionary  rules,  there  must  persist  to  a  degree 
an  element  of  danger  in  houses  occupied  bj^  consumptives.  For  this 
and  other  obvious  reasons  it  is  expedient  to  keep  the  children  in  the 
open  air  as  much  as  practicable,  and  to  send  them  awaj'  to  the  country, 
seashore,  or  mountains  when  possible  so  to  do.  The  children  of  the 
poor,  to  whom  these  luxuries  are  denied,  should  be  sent  to  the  open 
parks  of  the  large  cities  and  kept  away  from  the  squalor  of  noisome 
tenement  houses  and  dark  alleys.  WTiile  the  poverty,  ignorance,  and 
miser)-  of  their  parents  residing  in  densely  crowded  districts,  effectually 
preclude  the  acquirement  of  suitable  hygienic  conditions  at  home, 
the  children,  as  a  result  of  S3'stematic  effort,  may  be  drawn  to  the  sun- 
shine, fresh  air,  and  other  attractions  of  the  public  parks.  It  is  highly 
important  that  societ}^  should  be  educated  to  the  point  of  providing 
country  resorts  for  the  temporary  sojourn  of  unfortunate  children,  to 
whom  fresh  air,  good  food,  and  kindly  treatment  have  previously  been 


WHAT    THE    PUBLIC    SHOULD    KNOW  599 

unknown.  Provision  of  this  character  must  prove  not  only  a  veritable 
blessing  to  the  poor,  but  as  well  a  successful  feature  in  the  campaign 
of  prevention. 

As  children  advance  to  the  age  of  school  life,  the  problem  of  pro- 
phylaxis assumes  still  greater  proportions.  AdcUtional  factors  are  en- 
countered in  the  housing  of  a  large  number  of  pupils  in  comparatively 
small  apartments,  often  with  deficient  ventilation  and  improper  heating 
facilities,  the  more  or  less  intimate  contact  with  tuberculous  children, 
if  not  with  consumptive  teachers,  and  finally  the  proverbial  careless- 
ness of  school-children  in  regard  to  their  personal  habits,  or  an  utter 
defiance  of  sanitary  rules.  The  selection  of  suitable  sites  for  school- 
buildings,  the  details  of  construction,  inclusive  of  ventilation  and  heat- 
ing, the  hygienic  care  of  the  rooms,  and  the  general  supervision  of 
teachers  and  pupils  will  be  discussed  in  connection  with  the  adminis- 
trative control  of  tuberculosis  in  the  following  section. 

Efforts  toward  the  protection  of  children  should  not  partake  simply 
of  the  distribution  of  printed  mandatory  rules  which,  without  explana- 
tory interpretation,  will  be  completely  ignored  in  the  majority  of  in- 
stances. Attention  has  been  called  to  the  necessity  of  frequent  admoni- 
tions on  the  part  of  teachers  regarding  the  many  sanitary  improprieties 
of  school-children,  and  to  the  expediency  of  sending  concise  circular 
information  to  parents  in  the  hope  of  inculcating  habits  of  personal 
cleanliness  and  hygiene. 

An  important  phase  of  the  educational  movement  to  be  addressed 
to  parents  and  teachers  for  the  protection  of  the  young  consists  of 
an  appeal  to  increased  resistance  through  the  influence  of  proper  nutrition. 
It  is  a  matter  of  common  knowledge  that  the  majority  of  school-children 
are  underfed  and  poorly  nourished.  As  a  direct  result  they  exhibit 
weakened  powers  of  resistance.  Although  susceptibility  to  infection 
is  greatly  increased  by  the  feebleness  of  constitution  and  anemia  thus 
engendered,  the  demands  of  a  growing  child  in  the  way  of  superali- 
mentation are  but  little  appreciated  by  parents.  Opportunity  to  re- 
ceive light  nourishment  between  meals  is  not  afforded  to  school- 
children, no  matter  how  urgent  the  need,  save  in  the  hasty  swallowing 
of  candy,  corn-balls,  or  other  sweet  preparations  at  recess.  In  some 
cities  the  one  session  system  is  in  vogue,  admitting  merely  of  the  in- 
gestion of  a  cold  lunch  at  the  noon  hour.  Whatever  may  be  the  sup- 
posed advantages  of  the  single  session  which  ends  at  three  o'clock  in 
the  afternoon,  it  is  difficult  to  understand  how  sufficient  benefit  can  be 
derived  to  compensate  for  the  loss  of  a  hearty  meal  partaken  at  home 
in  the  middle  of  the  day.  It  is  high  time  that  the  attention  of  parents 
and  educational  authorities  be  directed  to  the  actual  needs  of  a  large 
proportion  of  children  for  decidedly  more  nourishment  than  is  provided 
for  them  at  present.  Even  the  serving  of  milk  or  sandwiches  at  recess, 
as  recommended  by  Dr.  S.  A.  Knopf,  would  be  productive  of  excellent 
results — assuredly  more  satisfactory  than  the  purchase  of  fruits  and 
sweets. 

Other  features  in  the  cause  of  prevention  among  school-children 
concerning  which  the  public  should  be  instructed  are  the  advantages 
of  daily  class  breathing  exercises,  with  other  systematically  conducted 
gymnastics,  and  the  necessity  of  clothing  more  perfectly  adapted  to 
seasonal  requirements.  The  distinct  benefits  afforded  by  carefully 
performed  respiratory  gymnastics  are  too  well  understood  to  justify 


600  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

enumeration,  but  it  is  important  to  bear  in  mind  that  under  proper 
conditions  of  weather  their  efficiency  may  be  increased  if  conducted 
in  the  open  air.  Insufficiency  of  clothing  is  undoubtedly  a  factor  of 
some  importance  in  the  development  of  conditions  favoring  the  spread 
of  tuberculosis  among  children.  In  fact,  the  inadequacy  of  dress 
among  the  young  is  such  in  many  cases  to  occasion  wonder  that  even 
a  greater  number  do  not  become  susceptible  to  infection.  It  is  idle 
to  comment  upon  the  necessities  of  the  very  poor  and  the  inevitable 
paucity  of  their  clothing,  but  to  supply  the  needs  of  such  unfortu- 
nates falls  within  the  province  of  charitable  if  not  antituberculosis 
organizations.  It  is  worthy  of  comment,  however,  that  the  children 
of  the  well-to-do  are  sometimes  clothed  as  improperly  as  those  whose 
parents  are  in  less  comfortable  circumstances.  Discretion  and  good 
judgment  in  the  matter  of  children's  dress  do  not  always  go  hand  in 
hand  with  a  fortunate  financial  status.  While  any  discussion  bearing 
upon  the  details  of  needed  dress  reform  for  children,  particularly  girls,  is 
hardly  appropriate  in  connection  with  the  prophylaxis  of  consumption, 
it  is,  nevertheless,  opportune  to  call  attention  to  the  fact  that  among 
children  far  less  consideration  is  given  to  the  proper  protection  of  the 
body  than  among  adults.  This  is  particularly  true  with  reference  to 
the  insufficient  covering  of  the  limbs,  the  use  of  unsuitable  undergar- 
ments, the  frequent  absence  of  rubbers,  stout  shoes,  warm  gloves,  or 
heavy  outer  apparel.  The  correction  of  this  treatment  of  young  chil- 
dren constitutes  one  feature  of  the  movement  toward  popular  education. 

By  all  odds  the  most  glai-ini^  ami  vicious  alnise  of  the  young,  which 
also  represents  a  most  potcni  Inctin'  in  tlic  (k'velopment  of  tuberculosis 
at  an  early  age,  is  found  in  (he  >  injiIoi/iik  id  uj  child  labor.  Opportunities 
for  diversion  and  recreation  in  the  open  air  are  absolutely  essential 
for  the  nurture  and  well  being  of  children.  The  wanton  restraint  of 
natural  health-giving  proclivities,  with  denial  of  fresh  air  and  sunshine 
through  long  hours  of  confinement  in  ill-ventilated  workshops,  results 
in  an  early  acquired  predisposition  to  tuberculosis.  The  public,  which 
blindly  permits  criminal  disregard  for  the  laws  of  health,  decency,  and 
humanity  through  failure  to  enact  and  enforce  regulations  pertaining  ta 
child  labor,  must  be  prepared  to  pay  the  penalty  exacted.  This  relates 
to  the  creation  of  fresh  centers  of  tuberculous  infection,  the  greater 
distribution  of  other  diseases,  the  development  of  alcoholism  and 
various  forms  of  dissipation,  the  tendency  toward  youthful  degener- 
acy, the  increased  suffering  of  families,  and  an  economic  loss  to  society 
of  no  mean  proportions. 

In  the  years  of  approaching  manhood  and  ivomanhood  young  people 
should  be  urged  to  lend  attentive  ears  to  the  lessons  of  hygienic  science, 
in  their  relation  not  only  to  ventilation  and  cleanliness,  but  more  par- 
ticularly to  the  baneful  effect  of  alcohol,  and  the  detrimental  physical 
consequences  of  late  hours,  with  other  forms  of  overindulgence.  Pro- 
longed and  undisturbed  sleep  at  this  time  of  life  is  prerequisite  for  sound 
health  and  physical  endurance.  Intemperance  of  any  kind,  be  it  alco- 
holic or  athletic,  a  reckless  abandonment  to  social  dissipation,  or  an 
undue  devotion  to  study,  must  surely  sap  the  energies  of  the  young, 
and  impair  their  u.sefulness  in  after-life,  if  not  making  them  an  earlier 
and  easier  prey  to  the  consuming  ravages  of  tuberculosis.  In  later 
years  a  similar  diminution  of  individual  resistance  is  found  in  the  ner- 
vous and  physical  strain  incident  to  overwhelming  business  cares  and 


ADMINISTRATIVE    CONTROL  601 

responsibilities,  the  dabbling  in  speculation,  with  its  frequent  financial 
reverses,  and  the  multitudinous  social  and  domestic  obligations  devolv- 
ing upon  the  modem  housewife  even  in  small  families.  It  is,  therefore, 
of  the  utmost  importance  in  the  midst  of  the  insistent  demands  im- 
posed by  an  active,  if  not  strenuous,  civilization,  that  due  cognizance  be 
taken  as  to  the  inevitable  drain  upon  individual  resistance,  and  the  vital 
necessity  for  all  possil^le  conservation  of  energy.  It  should  be  made 
clear  that  undue  alcoholic  stimulation  directly  predisposes  to  tubercu- 
losis, and  in  no  wise  retards  the  advance  of  an  infection  once  estab- 
lished. Its  pernicious  influence  upon  the  physical  health  and  the  de- 
velopment of  character  should  be  explained  in  the  school-room  through 
the  use  of  reputable  text-books  expounding  clearly,  without  hysteric 
distortion  of  facts,  its  physiologic  a.ction  and  toxic  properties. 

Young  men,  enamored  by  the  glitter  of  abnormal  athletic  accom- 
plishments, should  be  warned  of  the  inherent  dangers  resulting  from 
the  continuous  practice  of  arduous  feats.  While  a  sane  indulgence  in 
nearly  all  forms  of  outdoor  sjDorts  tending  to  healthy  physical  develop- 
ment and  recreation  should  be  encouraged,  no  means  should  be  spared 
to  acquaint  the  young  with  the  folly  of  the  slightest  indiscretion  in  their 
ambition  to  excel  in  this  respect.  As  stated  in  earlier  chapters,  clinical 
experience  bears  out  the  assertion  that  athletes  are  especially  prone  to 
tuberculosis  and  succumb  to  the  disease  even  more  readily  than  those 
unaccustomed  to  feats  of  prodigious  strength.  The  loss  of  sleep  and  of 
mental  rehabilitation  entailed  by  excessive  social  indulgence  or  over- 
study  should  be  emphasized  to  the  youth  as  an  unfailing  cause  of  nervous 
strain  and  physical  impairment.  The  consequences  of  overtaxing  the 
resources  of  the  individual  and  the  increased  likelihood  of  tuberculous 
infection  should  be  made  a  matter  of  common  every-day  knowledge. 


CHAPTER   LXXXVIII 

ADMINISTRATIVE  CONTROL 

Considerable  stress  has  been  laid  upon  the  necessity  of  organized 
effort  for  the  education  of  the  7nasses  as  a  fundamental  factor  in  the 
successful  control  of  tuberculosis.  In  spite  of  a  vigorous  educational 
propaganda  already  inaugurated  by  enthusiastic  workers,  there  is  still 
exhibited  a  deplorable  degree  of  pul^lic  apathy  and  indifference.  It 
is  apparent  that  such  enlighteiiincut  nf  the  people  as  will  insure  an 
active  universal  movement  tow.ud  incMiition  can  be  effected  only 
through  the  process  of  years,  pendinn  w  liiili  ii  is  essential  that  aggressive 
restrictive  measures  be  instituted,  when  necessary,  by  public  authorities. 
In  order  at  this  time  to  secure  a  beginning  control  of  the  pestilence, 
it  becomes  the  duty  of  the  Commonwealth  to  exercise  an  arlDitrary  super- 
vision over  certain  features  of  the  tuberculosis  problem.  1  he  necessity 
of  compulsory  notification  and  registration  has  been  di-i  u>mm|  at  some 
length,  as  well  as  the  advantages  accruing  from  public  instil  utiuual  pro- 
vision for  indigent  consumptives.  Other  dominating  considerations 
in  the  matter  of  administrative  control  relate:  (1)  To  the  suppression 


602  PROPHYLAXIS,    GEXERAL    AXD    SPECIFIC    TREATMEXT 

of  promiscuous  expectoration  in  public  places;  (2)  the  regulation  of 
schools;  (3)  the  inspection  of  food-supply;  (4)  the  control  of  patent 
medicines  and  the  restriction  of  medical  practice;  (5)  the  demand  for 
hygienic  construction  and  sanitary  supervision  of  public  buildings  and 
conveyances,  factories,  tenement  houses,  and  commercial  establishments. 

Control  of  Expectoration. — Indiscriminate  expectoration  is  known 
to  be  responsible  in  a  large  measure  for  the  transmission  of  consumption 
from  one  incU\-idual  to  another.  With  a  suitable  disposal  of  the  spu- 
tum under  all  circumstances,  tuberculosis  would  undoubtedly  diminish 
to  a  vast  extent,  and  it  would  seem,  therefore,  that  the  enforcement  of 
stern  measures  looking  toward  the  mitigation  of  the  spitting  evil  should 
become  obligatory  upon  all  municipal  authorities.  It  also  appears 
that  no  valid  objection  can  be  interposed  on  the  part  of  the  public  against 
the  summary  suppression  of  the  nuisance.  Society  has  been  informed 
repeatedly  as  to  the  direful  consequences  of  indiscriminate  expectoration, 
yet  this  disgusting  practice  is  indulged  in  daily  by  careless,  non-ignorant 
individuals,  who  are  utterly  indifferent  to  the  rights  of  others.  Regu- 
lations have  been  enacted  to  abate  the  indecent  and  pernicious  custom, 
placards  of  warning  have  been  posted  in  street-cars  and  public  places,  but 
even  ruthless  violation  of  the  law  is  seldom  followed  by  arrest  or  the  impo- 
sition of  a  penalty.  It  is  evident  that  ordinances  governing  this  practice 
must  remain  a  dead  letter  until  public  sentiment  is  awakened  to  a  real- 
ization of  the  actual  danger  from  an  unclean  and  inexcusable  habit. 
When  the  happy  state  of  affairs  shall  be  reached  that  society  will  rise 
in  its  wrath,  demand  the  rigid  enforcement  of  the  law  and  the  exac- 
tion of  the  maximum  punishment  to  violators,  no  longer  will  the  public 
eye  be  offended  by  unsightly  printed  notices  calling  attention  to  a 
personal,  if  not  national,  impropriety.  The  necessity  for  such  signs  is 
indeed  a  reproach  to  the  intelligence  and  civilization  of  any  community 
in  which  they  are  exhibited.  While  considerable  opposition  may  be 
expected  in  many  localities  from  the  arbitrarv^  execution  of  the  anti- 
spitting  ordinances  and  much  personal  humiliation  unavoidably  imposed, 
the  remedy  for  the  evil  lies  at  present  in  the  summary  action  of  fearless 
municipal  authorities.  Verbal  warnings  to  pedestrians  or  the  handing 
of  printed  cards  have  thus  far  proved  of  slight  avail.  In  some  cities 
the  practice  of  indiscriminate  spitting  has  been  curtailed  to  a  great 
extent.  It  is,  of  course,  apparent  that  the  people  must  have  some  place 
in  which  to  expectorate,  and  should  under  no  circumstances  swallow 
the  sputum.  To  those  unprovided  with  pocket  cuspidors  or  gauze, 
opportunity  should  be  afforded  to  expectorate  in  closed  sanitary  cus- 
pidors in  public  places.  These  should  be  self-flushing,  with  sewer  con- 
nection. 

Regulation  of  Schools. — The  regulation  of  schools  and  school  life 
should  begin  with  the  selection  of  a  proper  site.  An  open  elevated 
space  should  be  reserved  if  possible  for  this  purpose  in  sections  removed 
as  far  as  practicable  from  tall  buildings  or  large  chimneys.  Wherever 
the  location,  it  is  absolutely  essential  that  the  playground  be  spacious 
and  well  kept.  An  important  function  of  municipal  government  pertains 
to  the  supervision  of  the  construction  of  school-buildings.  Important 
details  to  be  observed  are  the  facilities  for  ventilation,  sunshine,  and 
heating.  All  rooms  should  be  high  posted  and  provided  with  numerous 
large  windows,  which  should  be  kept  open,  whenever  possible,  without 
subjecting  the  occupants  to  direct  drafts. 


ADMINISTRATIVE    CONTROL  603 

Forced  ventilation  should  be  employed  in  all  buildings  of  this 
nature,  the  hot  air  being  driven  into  the  upper  portion  of  the  room  and 
an  exit  provided  near  the  floor.  Experience  has  shown  that  a  properly 
equipped  ventilating  and  heating  apparatus  should  provide  a  complete 
change  of  air  within  a  very  few  minutes,  and  yet  maintain  an  equable 
temperature  within  the  room.  For  this  purpose  the  entrance  of  cold 
air  in  the  basement  is  followed  by  its  passage  over  a  tempering  coil,  by 
means  of  which  the  temperature  is  raised  to  the  neighborhood  of  from 
sixty-five  to  seventy-five  degrees.  It  then  is  forced  by  means  of  a  fan 
into  a  mass  coil  chamber,  from  which  exits  are  provided  to  different 
rooms,  the  temperature  being  regulated  by  dampers  automatically 
adjusted  by  thermostats.  The  heated  air  should  be  driven  into  the 
rooms  at  a  distance  of  about  eight  feet  from  the  floor,  permitting  its 
circular  distribution  and  diffusion  to  all  portions  of  the  apartment.  The 
exit  near  the  floor  should  be  upon  the  same  side  of  the  room  as  the  point 
of  ingress,  in  order  to  avoid  a  direct  draft.  By  a  proper  adjustment  of 
all  parts  of  the  heating  and  ventilating  plant  according  to  the  size  of  the 
room,  it  is  estimated  that  from  2500  to  3000  cubic  feet  of  fresh  air  may 
be  supplied  to  each  pupil  in  the  course  of  an  hour. 

It  is  desirable  that  the  greatest  degree  of  care  should  be  observed 
in  the  daily  cleaning  of  all  school-rooms,  this  being  performed  strictly 
in  accordance  with  modern  methods,  which  preclude  the  raising  of  any 
appreciable  quantity  of  dust.  School-rooms  ought  not  to  be  used  for 
public  or  social  gatherings  in  the  evening,  on  account  of  the  difficulty  in 
obviating  the  danger  of  careless  expectoration.  If  used  for  lecture 
purposes,  the  rooms  should  be  thoroughly  aired  before  the  children  are 
permitted  to  reenter,  and  the  floors  and  desks  washed  with  a  weak  solu- 
tion of  formaldehyd.  It  is  unwise  to  employ  any  teacher  who  is  known 
to  have  tuberculosis,  and  the  presentation  of  a  certificate  of  health  from 
a  recognized  authority  ought  to  accompany  all  applications  for  positions. 
In  case  of  doubt,  the  teacher  should  be  compelled  to  submit  to  an  exam- 
ination by  competent  medical  men  designated  for  this  purpose.  Chil- 
dren should  be  required  to  pass  inspection  from  time  to  time  by  medical 
examiners,  who  should  make  periodic  visits  to  the  various  departments 
and  conduct  a  physical  inquiry  whenever  necessary.  No  pupil  found  to 
be  the  subject  of  tuberculosis  should  be  permitted  to  attend  school,  and 
no  employe  suffering  from  the  disease  should  be  retained  in  his  position. 
All  teachers  found  to  have  contracted  tuberculosis  while  in  the  discharge 
of  official  duties  are  justly  entitled  to  retirement  upon  one-half  or  one- 
third  pay.  It  is  well  known  that  no  class  of  people  occupying  equally 
responsible  positions  receive  such  inadequate  remuneration  as  the 
teachers  in  our  public  schools.  Society  can  well  afford  to  donate  an 
annual  stipend  to  those  incapacitated  by  disease,  which  was  acquired 
while  in  active  service. 

Inspection  of  Food-supply. — The  control  of  animal  food-supply 
must  embrace  an  administrative  supervision  of  dairies  and  slaughter- 
hou.ses,  with  a  detailed  inspection  of  their  products.  It  is  not  sufficient 
to  rest  with  the  employment  of  the  tuberculin  test  upon  cattle  at  infre- 
quent intervals.  All  establishments  should  be  subjected  to  rigid 
investigation  from  time  to  time,  and  facts  elicited  as  to  the  conditions 
under  which  the  animals  are  housed  and  kept.  Cleanliness  of  the  stables, 
cows,  attendants,  and  utensils  must  be  regarded  as  a  sine  qua  non  for  the 
issuance  of  a  license,  without  which  no  farmer  should   be  permitted 


604  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

to  sell  milk.  It  is  essential  that  the  control  of  these  matters  should 
include  a  definite  limitation  of  the  number  of  cows  to  be  cared  for  by 
each  attendant.  It  has  been  the  dictum  of  some  students  and  educators 
for  years  that  all  cattle  respondmg  to  the  tuberculin  test  should  be  con- 
demned, the  loss  being  sustained  either  by  the  State  alone  or  jointly  with 
the  owners.  The  experiment  has  been  tried  m  several  States  and  found 
almost  impracticable,  on  account  of  the  prohibitive  cost  even  when  a 
portion  of  the  loss  is  borne  by  the  owner.  Bovine  tuberculosis,  however, 
as  shown  by  herd  inspection,  has  become  somewhat  less  prevalent  in 
these  States.  In  the  light  of  recent  scientific  research  it  is  clear  that 
immunization  of  cattle  may  be  reduced  to  a  practical  working  basis 
through  the  inoculation  of  attenuated  living  cultures  of  tubercle  bacilli, 
thus  minimizing  the  magnitude  of  the  annual  loss  to  owners  of  cattle. 

The  inspection  of  all  animal  food  offered  for  public  consumption 
should  be  made  as  thorough  as  that  practisetl  by  the  federal  government 
in  relation  to  the  meat  offered  to  the  export  trade.  In  some  instances 
the  meat  intended  for  home  consumption  throughout  the  United 
States  is  either  not  inspected  at  all,  or  so  superficially  as  to  rob  the 
procedure  of  any  practical  value.  The  control  of  the  milk-supply 
should  consist  of  more  than  the  detection  and  correction  of  impurities 
or  diluents.  While  the  maintenance  of  a  required  standard  of  milk 
should  be  enforced  by  municipal  authorities,  it  is  important  that  there 
be  instituted  a  strict  surveillance  of  the  animals  and  premises  where 
the  product  is  obtained.  No  milk  from  tuberculous  cows  shoidd  be 
offered  for  sale,  and  such  animals,  if  not  destroyed,  should  be  segre- 
gated from  the  rest  of  the  herd  during  the  employment  of  the  vaccine 
treatment.  Competent  and  fearless  inspection  of  dairies  is  not  to  be 
expected  if  appointments  to  the  position  are  obtained  as  a  mark  of 
political  preferment.  Devotion  to  the  work,  attention  to  detail,  and 
the  strictest  integrity  and  impartiality,  combined  with  the  courage  of 
one's  convictions,  are  essential  qualifications  for  those  upon  whom 
devolve  the  responsibilities  of  food  inspection. 

Control  of  Patent  Medicines  and  Restriction  of  Medical  Prac- 
tice.— The  patent  medicine  evil  is  responsible  for  many  of  the  ills  visited 
upon  mankind  during  the  present  generation.  Through  the  influence 
and  under  the  auspices  of  the  American  Medical  Association  recent 
attention  has  been  called  in  a  convincing  manner  to  the  prodigious 
consumption,  and  the  detrimental  effect  upon  the  health  of  iniqui- 
tous preparations  foisted  upon  the  public  under  the  name  of  proprie- 
tary medicines.  The  vast  majority  of  these  nostrums  contain  large  per- 
centages of  alcohol,  to  say  nothing  of  other  injurious  .substances,  the 
nature,  dosage,  and  effect  of  which  are  entirely  unknown  to  the  consumer. 
An  infinite  amount  of  harm  is  produced  by  the  swallowing  of  these 
deleterious  preparations,  which  are  offered  to  an  unsuspecting  people 
under  the  guise  of  harmless  remedies.  The  proprietors,  imhandicapped 
by  scientific  knowledge  or  conscience,  usually  succeed  in  enlisting  for  a 
consideration,  the  cooperation  and  assistance  of  otherwi.se  reputable 
citizens.  Flamboyant  advertisements  as  to  the  virtues  of  these  prepara- 
tions, guaranteed  to  cure  all  diseases  of  men,  women,  and  children,  are 
often  accompanied  by  testimonials  from  clergymen  and  men  in  public 
life,  together  with  their  photographs.  It  is  worthj'  of  more  than  pass- 
ing comment  that  the  more  glaring  the  deception,  the  more  pernicious 
the  nostrum,  and  the  more  extravagant  and  unreasonable  the  claims  of 


ADMINISTRATIVE    CONTROL  605 

promoting  fakirs,  the  more  likely  are  quasi-intelligent  citizens  to  become 
inveigled  into  lending  their  unqualified  indorsement.  Waiving  the  mani- 
fest impropriety  in  permitting  their  names  to  be  attached  to  false  and 
blandishing  testimonials,  the  situation  is  dominated  by  the  deplorable 
fact  that  these  well-meaning  people  are  instrumental  in  the  production 
of  untold  misery  and  in  abetting  an  evil  which  represents  one  of  the 
greatest  curses  of  our  present  civilization.  It  is,  indeed,  to  be  regretted 
that  some  reverend  gentlemen,  even  though  unintentionally,  should 
assume  the  fearful  responsibility  of  leading  others  to  lives  of  alcoholism 
and  habits  of  cocain  degeneracy.  Were  the  extent  of  the  nuisance 
limited  to  a  financial  loss  on  the  part  of  the  people,  or  even  to  the  delay 
thus  occasioned  in  seeking  competent  medical  counsel,  the  evil  would 
still  assume  sufficient  proportions  to  demand  the  enactment  of  vigorous 
legislative  measures  toward  its  suppression.  Unfortunately,  however, 
the  baneful  consequences  of  yielding  to  alluring  advertisements  of  this 
nature  are  decidedly  more  far  reaching.  Recourse  to  quack  nostrums 
on  the  part  of  the  ill  is  often  attended  with  loss  of  valuable  time  before 
the  recognition  of  the  disease  and,  worse  still,  loss  of  the  opportunity  to 
secure  arrest.  In  view  of  these  considerations  of  fact  relating  to  the 
undermining  of  health,  there  is  imposed  upon  the  State  an  obligation 
to  restrict  the  wholesale  consumption  of  these  fraudulent  and  vile  con- 
coctions, and  to  control  the  character  oj  medical  advertisements  in  the 
public  press.  The  American  people  are  greatly  in  need  of  protection 
from  unscrupulous  and  ignorant  vendors  of  sure  cures  for  consumption. 
The  loss  to  the  unfortunate  victim  of  these  pretentious  discoverers  of 
special  methods  of  treatment  is  quite  beyond  the  power  of  estimation. 
The  poor,  who  constitute  the  class  more  frequently  deluded  by  their 
representations,  are  robbed  at  the  very  beginning  of  the  savings  of  a 
lifetime.  After  the  lapse  of  a  few  weeks  or  months,  during  which  they 
have  dragged  themselves  wearily  to  offices  for  the  inhalation  of  pungent 
or  aromatic  vapors,  they  are  wantonly  left  to  their  own  resources,  ill 
prepared,  by  reason  of  impaired  finances  and  abandoned  hope,  to  cope 
with  the  exigency  of  their  present  situation.  While  reputable  physicians, 
impelled  to  seek  change  of  residence  in  the  various  States,  are  subjected 
to  much  unnecessary  embarrassment  in  order  to  qualify  satisfactorily 
before  State  examining  boards,  the  law  in  many  localities  refuses  to  take 
cognizance  of  the  iniquitous  practice,  indulged  in  by  unworthy  and 
degenerate  physicians,  who  have  previously  succeeded,  through  devious 
means,  in  securing  diplomas  or  passing  examinations. 

THE  DEMAND  FOR  HYGIENIC  CONSTRUCTION  AND  SANITARY 
SUPERVISION  OF  TENEMENT  HOUSES,  WORKSHOPS  OR  FACTO- 
RIES, COMMERCIAL  ESTABLISHMENTS,  PUBLIC  BUILDINGS,  AND 
CONVEYANCES 

The  regulation  of  tenement-house  construction  through  legal  enact- 
ment constitutes,  without  doubt,  an  exceedingly  important  feature  of 
a,dministrative  control.  While  there  can  be  no  excuse  for  the  faulty 
construction  of  such  buildings,  containing  an  innumerable  quantity  of 
small  dark  rooms  and  furnishing  an  abode  for  countless  people,  it  must 
not  be  assumed  that  absence  of  sunshine,  insufficient  ventilation,  and 
unsanitary  plumbing  are  the  only  factors  responsible  for  making  these 
structures  prolific  breeding-spots  for  tuberculosis.  The  squalor,  filth, 
misery,  ignorance,  and  poverty  of  the  occupants  are  assuredly  not  to  be 


bOb  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

ignored  as  important  etiologic  considerations.  These  unfortunate  con- 
ditions would  obtain  to  a  large  extent  even  were  such  buildings  con- 
structed in  accordance  with  sanitary  regulations.  Without  the  observ- 
ance of  general  hygienic  conditions  by  people  dwelling  in  tenement 
houses,  municipal  prophylactic  efforts  would  remain  unavailing  even 
in  rooms  of  adequate  size,  with  large  windows  permitting  the  entrance 
of  sunshine  and  fresh  air.  Upon  the  other  hand,  in  small,  dark,  ill- 
ventilated  rooms  and  halls,  the  maintenance  of  perfect  cleanliness 
is  insufficient  in  itself  to  prevent  the  deterioration  of  health  and  the 
development  of  physical  conditions  favoring  infection.  While  impure 
air  and  excessive  crowding  of  people  within  a  limited  area,  are  important 
factors  in  the  development  of  tuberculosis,  these  are  accentuated  by 
the  filth,  and  utter  neglect  by  tenement-house  occupants  to  observe 
sanitary  conditions. 

Some  students  of  medicosociologic  affairs  have  described  in  graphic 
terms  the  criminal  disregard  for  the  laws  of  hygiene  in  the  building  of 
tenement  houses,  to  which  is  ascribed  a  large  measure  of  the  responsi- 
bility for  the  spread  of  tuberculosis.  An  abuse  of  this  kind  constitutes 
but  a  single  factor  in  the  general  problem  pertaining  to  the  develop- 
ment of  consumption  among  a  class  of  people  peculiarly  predisposed  as 
the  result  of  a  great  variety  of  causes.  It  is  true  that  an  appalling  preva- 
lence of  tuberculosis  has  been  observed  in  the  tenement-house  districts 
of  many  of  our  larger  cities.  Certain  blocks  have  been  designated  as 
"lung  blocks,"  by  reason  of  the  frightful  distribution  of  the  disease  in 
these  localities.  It  is  also  true  that  the  ignorance  and  filth  in  these 
places  are  quite  as  revolting  as  the  faults  of  building  construction.  The 
tenement-house  evil,  therefore,  seems  to  present  two  important  indica- 
tions for  immediate  reform,  i.  e.,  the  regulation  of  construction  by  State 
or  municipal  government,  and  the  removal  of  squalid  unsanitary  con- 
ditions. 

The  preceding  considerations  apply  with  almost  equal  force  to 
workshops  and  factories,  and,  in  fact,  to  all  manufacturing  and  commer- 
cial establishments.  Certain  occupations  have  long  been  regarded, 
both  by  the  laity  and  the  profession,  as  inimical  to  health. 

Attention  has  been  called  to  the  prevalence  of  the  disease  among 
cigar-makers,  shoemakers,  tailors,  machinists,  factory  operatives,  laun- 
dry workers,  stone-cutters,  and  upholsterers.  It  must  be  admitted  that 
a  few  occupations  directly  favor  infection  on  account  of  the  unusual 
opportunities  afforded  for  the  inhalation  of  fine  particles  of  dust,  which 
may  serve  not  only  as  carriers  of  tubercle  bacilli,  but  also  as  agents  of 
irritation  to  mucous  surfaces.  This  is  particularly  true  of  weavers,  millers, 
machinists,  stone-cutters,  miners,  and  potters.  It  is  probably  true,  as 
has  been  described,  that  the  detrimental  effects  consist,  in  part,  of  the 
development  of  chronic  catarrhal  conditions  of  the  mucous  meml^ranes, 
as  a  remote  effect  of  which  the  resistance  to  tuberculous  infection  is 
diminished.  There  are  many  other  pursuits,  however,  exhibiting  a 
frightful  mortality  rate  from  tuberculosis,  in  which  the  inhalation  of 
dust  from  any  source  cannot  be  regarded  as  a  definite  etiologic  factor. 
The  disease,  however,  has  been  supposed  to  claim  an  appalling  number 
of  victims  bj'  virtue  of  some  mysterious  influence  incident  to  the  occu- 
pation. In  many  instances  there  obtain  widely  diverse  unfavorable 
conditions,  which  are  definitely  responsible  for  the  development  of 
consumption.     These  are  not  always  peculiar  to  the  occupation  and 


ADMINISTRATIVE    CONTROL  607 

the  conditions  under  which  workmen  are  employed,  but  are  inherent,  to 
some  extent,  to  the  particular  class  of  people  engaged  in  these  pursuits, 
their  previous  methods  of  existence,  their  poverty,  shiftlessness,  and 
habits  of  dissipation.  Thus  the  ignorant  and  underpaid  employe  in 
certain  lines  of  work,  which  demand  but  little  intelligence  or  training, 
is  non-resistant  to  disease  not  merely  through  a  direct  detrimental  effect 
of  the  occupation,  but  also  from  deficiency  of  nourishment,  inadequate- 
ness  of  clothing,  and  the  physical  drain  incident  to  previous  disease. 
Carelessness  of  expectoration  and  other  habits  of  personal  uncleanliness 
in  the  workshop  are  much  in  vogue  among  employes  of  the  foregoing 
description.  It  is  precisely  among  such  a  class  of  people  that  squalor 
and  filth  abound,  and  it  is  quite  as  reasonable  to  attribute  the  develop- 
ment of  consumption  to  the  effect  of  the  ten  or  fourteen  hours  spent  in  the 
home  as  to  the  eight  or  ten  passed  in  the  workshop.  It  is  not  desired  to 
minimize  the  unfavorable  influence  of  certain  occupations,  nor  to  dis- 
parage the  vital  need  of  better  facilities  for  ventilation  and  other  details 
of  hygienic  building  construction.  The  point  is  raised,  however,  that  a 
broad  consideration  of  the  problem  of  prevention  demands  in  many  indi- 
vidual instances  the  inclusion  of  other  factors  than  the  occupation  itself. 
While  employes  of  mills,  factories,  steam  laundries,  manufacturing 
and  printing  establishments  are  often  compelled  to  work  in  over- 
heated and  poorly  ventilated  apartments,  operatives  engaged  in  other 
industrial  occupations  are  often  prone  to  neglect  hygienic  consider- 
ations. There  has  been  advanced  no  substantial  reason  why  the 
shoemaker,  from  the  nature  of  his  work,  should  be  especially  liable 
to  the  development  of  tuberculosis,  either  from  direct  exposure  or 
through  diminution  of  individual  resistance,  yet  the  highly  unfavorable 
conditions  under  which  he  has  been  wont  to  toil  have  been  responsible 
for  an  alarming  mortality  rate.  The  shops  have  almost  invariably 
been  contracted,  low  posted,  and  dingy,  located  either  in  some  dark 
recess  or  basement,  unprovided  with  ventilation  of  any  description,  and 
often  superheated  to  a  degree  of  intolerance. 

Consumption  has  been  found  to  be  quite  prevalent  among  the 
employes  of  large  commercial  establishments,  the  chief  injurious 
factors  being  the  indoor  confinement  and  deficiency  of  ventilation. 
It  is  important  in  such  places  and  in  all  workshops  that  there 
should  be  adequate  provision  for  air-renewal.  In  many  department 
stores  the  facilities  for  ventilation  are  crude  and  imperfect,  and  as  a 
result  of  the  influx  of  people,  the  clerks  for  hours  at  a  time  are  compelled 
to  breathe  a  noxious  atmosphere.  Details  of  hygienic  construction 
should  be  arranged  in  accordance  with  the  purposes  for  which  such 
buildings  are  intended. 

The  necessity  of  proper  construction  and  careful  supervision  applies 
strongly  to  public  buildings  of  all  description.  It  is  a  regrettable  fact 
that  a  large  proportion  of  the  buildings  designated  for  the  use  of  the 
public,  possess  exceedingly  inadequate  facilities  for  ventilation,  par- 
ticularly post-offices,  federal  buildings,  court-houses,  and  in  many 
instances  State  capitols.  Even  the  halls  of  such  structures,  where 
people  are  wont  to  congregate  or  pass  to  and  fro,  are  often  redolent 
with  foul  air  and  sometimes  offensive  from  the  aggregation  of  filth. 
Cuspidors,  if  provided  at  all,  are  usually  of  improper  construction, 
rarely,  if  ever,  filled  with  water,  and,  as  a  rule,  insufficiently  cleansed. 
The  necessity  for  attention  to  details  of  hygienic  construction  and  per- 


bU»  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

feet  sanitary  cleanliness  appears  emphasized  by  the  indifferent  habits  of 
individuals  frequenting  such  buildings. 

In  all  commercial  establishments  and  factories,  as  well  as  in  public 
buildings,  rules  against  indiscriminate  expectoration  should  be  rigidly 
enforced,  and  sanitary  cuspidors  universally  provided.  It  is  insufficient 
to  post  notices  in  workshops  warning  employes  of  the  dangers  of  con- 
sumption and  calling  attention  to  the  necessity  of  compliance  with  de- 
tailed instructions.  Cooperation  of  operatives  must  be  secured  in  order 
to  make  any  organized  effort  effective.  To  this  end  the  employes  should 
be  privileged  to  receive  the  periodic  attendance  of  a  physician  free  of 
expense.  By  this  means  the  disease  may  be  recognized  at  an  early  stage, 
and  the  invalid  excused  from  the  workroom,  or  at  least  subjected  to  the 
closest  surveillance.  This  advances  an  important  feature  in  the  control 
of  tuberculosis,  i.  e.,  provision  for  the  detection  of  consumption  among 
employes  and  for  their  financial  assistance  when  incapacitated  by  disease. 
This  idea  has  been  amplified  to  a  considerable  extent  in  Germany,  where 
a  system  of  compulsory  insurance  for  working-people  is  in  vogue.  In 
1881,  under  the  influence  of  Kaiser  Wilhelm  der  Grosse,  workingmen's 
insurance  was  instituted  to  combat,  as  far  as  possible,  the  misery  and 
poverty  of  a  portion  of  the  laboring  class. 

The  operative  in  Germany,  who  is  compelled  by  law  to  join  the 
Government  Assurance  Association,  becomes  insured  against  sickness, 
accident,  invalidity,  and  old  age.  When  incapacitated  for  these  reasons 
he  is  entitled  to  assistance  for  himself  and  family,  and  a  vast  amount  of 
distress  is  effectually  prevented.  The  workingmen  are  divided  into  vari- 
ous classes  in  accordance  with  a  certain  wage  scale.  The  premiums  of 
sick  insurance  are  paid  through  the  employer,  who  contributes  one-third 
of  the  entire  amount,  deducting  the  other  two-thirds  from  the  wages  of 
the  employe.  In  case  the  latter,  through  physical  disability,  becomes 
unable  to  work,  he  receives  an  allowance  equal  to  one-half  his  wages 
for  a  period  of  many  weeks  and  sometimes  a  year,  and  receives,  in  addi- 
tion, free  medical  attention.  Provision  of  a  somewhat  similar  nature 
is  made  for  workingmen  insured  against  accident  or  invalidity.  Insur- 
ance against  old  age  and  invalidism  is  compulsory  to  every  person  follow- 
ing certain  prescribed  pursuits,  over  sixteen  years  of  age,  whose  annual 
wage  earnings  do  not  exceed  $500.  Through  the  beneficent  influence  of 
these  various  forms  of  insurance,  merging  more  or  less  into  one  organiza- 
tion, results  of  a  highly  important  nature  from  an  economic  and  humani- 
tarian .standpoint  have  been  secured.  An  essential  feature  of  the  propo- 
sition is  the  governmental  aid,  protection,  and  paternalism  so  highly 
characteristic  of  the  general  social  policy  in  Germany.  Although  a 
portion  of  the  burden  in  the  payment  of  premiums  is  borne  by  the  wage- 
earner,  there  is  introduced,  at  the  same  time,  the  element  of  governmental 
coercion,  intelligently  elaborated  to  meet  the  necessities  of  unfortunate 
social  conditions.  While  it  is  not  believed  that  in  America  a  detailed 
interpretation  of  the  German  insurance  laws  for  workingmen  could  be 
tolerated  on  account  of  the  spirit  of  individual  independence,  the  funda- 
mental principle  of  cooperation  and  as.sistance  in  its  practical  application 
to  the  needs  of  wage-earners  is  endowed  with  enormous  beneficent 
possibilities.  Certain  modifications  of  the  German  system  for  years 
have  been  in  vogue  among  the  employes  of  large  railway  corporations 
and  other  industrial  establishments.  These  voluntary  relief  associ- 
ations, which  sometimes  partake  more  or  less  of  the  nature  of  fraternal 


ADMINISTRATIVE    CONTROL  609 

organizations,  have  proved  to  be  immensely  effective  in  diminishing  dis- 
tress at  the  time  of  sicl^ness. 

Especial  importance  attaches  to  the  question  of  prison  reform,  as 
tuberculosis  has  ever  been  found  prevalent  in  penal  institutions.  WhUe 
the  disease  is  known  to  flourish  among  those  who  are  permitted  physical 
and  mental  occupation  in  the  workshops,  statistics  indicate  a  partic- 
ularly alarming  mortality  rate  among  convicts  subjected  to  close  con- 
finement. Although  there  are  certain  mitigating  conditions  to  be  offered 
in  explanation  of  the  spread  of  tuberculosis  in  prisons  and  reformatories, 
a  few  facts  may  be  adduced  which  even  magnify  the  abuse  of  hygienic 
laws  permitted  in  these  institutions. 

Many  prisoners,  when  admitted  to  State  penitentiaries,  have  been 
addicted  for  years  to  dissipation,  and  afflicted  with  direst  poverty. 
Some  of  these  unfortunates  have  become  tuberculous  as  the  result  of 
excesses  practised  during  lives  of  misery  and  degeneracy.  The  law,  not 
recognizing  that  tuberculosis  is  any  excuse  for  crime,  exacts  the  same 
penalty  from  the  sick  as  from  the  well.  Phthisical  individuals  are  not 
subjected  to  physical  examination  before  being  sent  to  these  institutions, 
and,  therefore,  are  a  decided  menace  to  their  fellow-convicts  for  indefi- 
nite periods  before  their  true  condition  is  recognized.  Many  are  sent 
to  the  crowded  workshops  to  pursue  some  industrial  occupation,  in  close 
proximity  to  others.  Some,  though  permitted  employment  in  the  open 
air,  are  compelled  to  perform  arduous  labor  far  beyond  their  physical 
strength.  Still  others,  who  are  subjected  to  solitary  confinement,  are 
necessarily  denied  fresh  air,  sunshine,  and  nourishing  food,  all  of  which 
are  demanded  for  their  unsuspected  tuberculous  condition.  The  effect 
of  these  injurious  factors  is  materially  augmented  by  the  psychic  influ- 
ence of  restraint,  the  absence  of  mental  diversion,  and  the  conflicting 
emotions  obtaining  in  the  majority  of  those  convicts  upon  whom  the 
solitary  confinement  is  impo.sed.  Added  to  these  influences  are  careless- 
ness in  the  personal  habits  of  the  inmates,  and  the  imperfect  ventilation 
of  cell-houses,  corridors,  and  all  rooms  occupied  by  convicts  for  industrial 
purposes. 

Some  criticism  may  justly  be  directed  to  the  imperfect  details  of 
architectural  construction  and  the  lack  of  enforcement  of  necessary 
hygienic  regulations  by  prison  authorities.  In  institutions  where 
discipline  in  all  other  respects  is  the  supreme  desideratum  of  oflScials, 
the  vital  element  of  hygienic  regime  should  not  be  disregarded.  Sani- 
tary cu.spidors  should  be  provided  for  the  convicts  and  instructions 
issued  with  reference  to  the  proper  disposal  of  the  expectoration, 
violation  of  rules  being  subject  to  reasonable  punishment.  There 
is  no  reason  why  the  cells  and  corridors  should  not  be  kept  scrupu- 
lously clean,  and  why  blankets  and  bedding  should  not  be  disinfected 
periodically.  A  systematic  investigation  from  time  to  time  regarding 
the  physical  condition  of  the  inmates  appears  absolutely  essential  as  a 
preliminary  feature  of  any  general  effort  toward  prevention.  Proper 
ventilation  should  be  provided  for  the  cells,  cell  houses,  and  workrooms, 
the  entire  problem  of  fresh  air-supply  being  as  obligatory  upon  the  atten- 
dants as  any  other  feature  of  prison  discipline.  It  is  desirable  that  the 
work  which  any  inmate  is  designated  to  perform,  should  be  adapted 
to  his  physical  condition.  The  pulmonary  invalid,  if  compelled  to  work, 
should  at  least  be  permitted  to  engage  in  some  light  occupation  in  the 
open  air  which  may  not  be  altogether  detrimental  to  his  physical  health. 


610  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

The  supervision  of  sleeping  apartments  in  hotels,  Pullman  cars, 
and  steamboats  must  be  regarded  as  an  important  step  in  any  organ- 
ized movement  toward  prevention.  But  little  has  been  done  in  any- 
State  in  the  way  of  supervision  of  hotels,  although  in  some  localities 
circular  information  has  been  freely  distributed.  There  should  be  an 
obligatory  notification  of  the  reception  of  consumptives  within  the 
hostelry  or  boarding-house,  after  which  the  health  officers  may  enforce 
the  observance  of  all  sanitary  precautions,  both  on  the  part  of  the  invalid 
and  the  attendants.  Thorough  disinfection  of  apartments,  inclusive 
of  carpets,  rugs,  furniture,  clothing,  blankets,  and  linen,  occupied  by 
'consumptives  should  be  made  fully  as  obligatory  in  hotels  as  in  private 
families. 

Especial  interest  attaches  to  the  supervision  of  public  convey- 
ances, and  particularly  to  the  enforcement  of  radical  precautionary 
measures  in  Pullman  sleeping-cars.  From  a  practical  standpoint,  the 
opportunities  for  infection  during  transportation  are  comparatively 
slight  in  ordinary  day-coaches  and  electric  cars.  As  people  usually  ride 
but  short  distances  in  these  conveyances,  the  accumulation  of  filth  and 
the  scattering  of  oral  excretion  are  rather  inconspicuous.  Upon  long 
journeys  advanced  pulmonary  invalids  are  often  confined  in  sleeping 
berths  for  several  days.  The  facilities  for  ventilation  are  much  better 
in  the  former  conveyances,  as  the  doors  are  opened  more  frequently  and 
greater  opportunity  afforded  for  direct  draft  than  in  the  Pullman  cars, 
with  their  winding  passages.  Therefore,  in  sleeping  coaches  the  possi- 
bility of  infection  during  transportation  is  of  especial  concern,  and  the 
necessity  of  stringent  regulations  a  paramount  consideration.  In  these 
conveyances  many  objectionable  features  are  almost  unavoidably  en- 
countered, among  which  must  he  nicntidiicil  primarily  the  presence  of 
unfortunate  consumptives,  p.-u  ti(iil;ul\-  updu  trains  running  to  and  from 
popular  health  resorts.  Muiiy  nf  these  individuals,  exhausted  by  disease, 
are  compelled  to  remain  in  the  drawing-room  or  berth,  while  the  cough  is 
often  aggravated  by  the  maintenance  of  the  recumbent  position  and  the 
inhalation  of  smoke  and  dust.  Innumerable  bacilli  are  scattered 
throughout  the  immediate  vicinity  of  the  invalid  as  a  result  of  the 
droplet  infection  incident  to  violent  cough.  The  expectoration  is  often 
deposited  upon  handkerchiefs  or  in  receptacles  utterly  inappropriate  for 
this  purpose.  Masses  of  sputum  remain  adherent  upon  the  upper  surface 
of  shallow  cuspidors,  and  are  exposed  for  long  hours  to  the  confined  and 
overheated  air,  while  blankets  and  linen  are  almost  inevitably  soiled  by 
the  excretions  from  the  mouth. 

No  opportunity  is  afforded  en  route  for  proper  ventilation  or  for 
sweeping  and  dusting  in  accordance  with  modern  methods.  Neither 
is  it  possible  to  effect  an  immediate  sterilization  of  blankets,  which 
are  packed  away  without  exposure  to  the  sun  or  fresh  air.  The  cars, 
as  a  rule,  are  either  greatly  overheated  or  uncomfortably  cold,  the 
maintenance  of  an  equable  temperature  with  adequate  ventilation 
being  necessarily  attended  with  the  greatest  difficulty.  People  obliged 
to  travel  long  distances,  therefore,  in  addition  to  the  other  discom- 
forts, are  often  subjected  to  direct  exposure  to  tuberculous  infection. 
Another  factor  of  some  importance  is  the  attention  of  the  porter,  who 
becomes  ubiquitous  at  the  end  of  the  journey,  and  with  the  ostentatious 
flourishing  of  the  whisk,  raises  clouds  of  dust  in  the  faces  of  passengers. 
It  is  apparent  that  public  protection  during  transportation  in  these 


ADMINISTRATIVE    CONTROL  611 

conveyances  can  be  secured  only  by  the  enactment  of  uniform  regulations 
throughout  the  United  States,  enforcing  the  maintenance  of  sanitary 
conditions.  Some  States  have  already  passed  laws  pertaining  to  car 
sanitation  within  their  borders,  while  others  have  made  no  effort  to 
secure  similar  legislation.  Much  prai.se  should  be  accorded  to  the 
Pullman  {'ompany  for  the  hygienic  efforts  undertaken  upon  their 
own  initiative.  During  recent  years  the  interior  furnishing  of  Pullman 
cars  has  been  made  more  simple,  thus  permitting  greater  ease  and 
thoroughness  of  cleaning.  Some  of  the  upholstery  has  been  dispensed 
with  and  a  portion  of  the  carpeting,  while  rubber  tilings  have  been  placed 
in  the  lavatories  and  smoking-rooms.  A  thirtl  sheet  has  been  provided 
to  protect  the  upper  blanket,  thus  minimizing  materially  the  danger  of 
wholesale  distribution  of  bacilli  upon  the  woolen  fabric.  Dr.  T.  R. 
Crowder,  Superintendent  of  Sanitation  for  the  Pullman  Company, 
states  that  immediately  the  car  enters  the  yard  after  completing  the 
trip,  the  seats,  cushions,  carpets,  blankets,  and  bedding  are  cleaned 
out-of-doors  by  means  of  compressed  air.  If  a  single  berth  is  known  to 
have  been  occupied  by  a  consumptive,  the  interior  woodwork  is  cleaned 
with  moist  cloths  and  the  entire  car  fumigated.  For  the  purpose  of 
disinfection,  formalin  is  left  to  evaporate,  with  all  the  berths  open,  for  a 
number  of  hours.  Supplementary  to  the  commendable  work  under- 
taken by  the  company  in  the  interests  of  more  perfect  sanitation,  it  is 
suggested  that  some  changes  are  needed  in  the  disposal  of  the  sputum. 
Undoubted  dangers  accompany  the  use  of  the  cuspidors  now  in 
vogue,  and  yet  manifest  disadvantages,  if  not  insuperable  objections, 
attend  the  employment  of  sanitary  floor  receptacles  for  sputum.  Cus- 
pidors at  present  in  use  are  shallow,  of  small  size,  incapable  of  holding 
water  or  a  disinfecting  solution,  and  quickly  become  filthy  by  the  reten- 
tion and  drying  of  sputum  upon  their  upper  surface.  Upon  the  other 
hand,  high  cylindric  cuspidors  containing  liquid  are  apparently  pre- 
cluded by  the  necessity  for  economy  of  space  and  the  continual  motion 
of  the  train.  For  these  reasons  it  appears  that  .some  other  provision 
should  be  made  for  the  disposal  of  the  sputum  than  the  use  of  floor 
cuspidors.  It  should  be  made  obligatory  upon  pulmonary  invalids 
traveling  in  these  conveyances  to  be  equipped  either  with  sanitary 
pocket  cuspidors  or  with  chee.se-cloth  and  bags  of  paraffined  paper,  oiled 
silk,  or  rublier.  The  dry  sweeping  of  cars  and  indiscriminate  dusting 
either  of  seats  or  individuals  should  not  be  permitted  in  transit.  Con- 
siderable difficulty  is  to  be  experienced  in  securing  a  proper  degree  of 
air-renewal  on  account  of  the  objections  raised  by  passengers.  Con- 
ductors, brakemen,  and  porters,  however,  should  be  instructed  to  give 
particular  attention  to  the  maintenance  of  as  thorough  ventilation  as 
is  practicable  by  means  of  the  doors,  windows,  and  transoms. 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


SECTION    11 
Treatment 


CHAPTER  LXXXIX 
GENERAL   CONSIDERATIONS 

There  is  demanded  in  the  management  of  no  disease  in  the  entire 
realm  of  medicine  the  exercise  of  such  slcill  and  judgment  on  the  part 
of  the  physician  as  is  required  for  the  intelligent  treatment  of  the  clinical 
manifestations  and  for  the  resourceful  control  of  the  tuberculous  indi- 
vidual. It  is  doubtful  if  the  trained  clinician,  accustomed  to  definiteness 
and  accuracy  of  opinion  born  of  wide  experience,  is  compelled  to  observe 
a  greater  regard  for  detail  or  a  more  sagacious  adaptation  of  means  to 
satisfy  imperative  and  often  conflicting  indications,  than  in  the  indi- 
vidualized treatment  of  pulmonary  hemorrhage. 

Notwithstanding  the  urgent  claim  upon  the  profession  for  a  sustained 
support  of  rational  conservative  measures  of  treatment,  there  ever  has 
been  in  evidence  a  lamentable  diversity  of  therapeutic  methods.  Even 
in  recent  years  numerous  remedies  and  wideh'  di\ergent  methods  have 
been  highly  vaunted  for  their  supposed  efficacj'.  Without  a  wise,  judi- 
cious guidance,  it  is  almost  impossible  for  the  student  in  perusing  the 
literature  extant,  to  select  the  authentic  reports,  the  substantiated  facts, 
and  the  mature  conclusions  from  the  superficial  observations,  the  erro- 
neous deductions,  and  the  fanciful  theories.  It  is  not  pleasant  to  contem- 
plate the  many  vagaries  of  medical  opinion  and  the  therapeutic  absurd- 
ities practised  even  in  recent  generations.  No  comment  is  necessary 
concerning  previous  inconsistencies  of  treatment  other  than  to  note  the 
facility  with  which  men  of  apparently  sound  minds  have  been  led  to 
embrace  unworthy  therapeutic  methods.  It  is  fortunate  that  the 
tendency  is  growing  to  refuse  a  blind  and  unthinking  acceptance  of 
prevailing  medical  fads  with  reference  to  the  management  of  a  disease 
which,  more  than  all  others,  demands  the  exercise  of  conservatism  and 
stability  of  judgment. 

Even  at  the  present  time  there  is  occasionally  manifested  an  incli- 
nation toward  the  formation  of  hasty  conclusions,  the  presentation 
of  inaccurate  data,  and  the  promulgation  to  the  profession  and  the 
general  public  of  irrational  opinions  with  reference  to  the  relative 
advantages  and  disadvantages  of  certain  remedial  measures.  The 
opinions  expressed  by  some  writers  in  the  height  of  their  exuberant 
enthusiasm  over  the  results  of  some  therapeutic  procedures  are  bizarre  in 
the  extreme.  Many  of  the  so-called  "  cures' '  which  are  flaunted  in  the 
face  of  the  profession  and  the  public  by  men  to  be  dcsi<;iiated  merely 
as  "optimistic"  are,  in  reality,  not  subject  to  verification  upon  the  basis 
of  the  physical  and  bacteriologic  findings.  While  consumption  is,  indeed, 
curable,  it  is  essential  for  the  public  to  be  informed  that  enduring  success 
in  this  respect  is  not  as  beatifically  simple  as  might  be  supposed  from 
some  of  the  current  literature.  It  is  desirable  that  the  people  should 
be  thoroughly  aroused  from  the  lethargy  and  resignation  prevailing  in 


GENERAL    CONSIDERATIONS  613 

former  years  as  to  the  fatality  of  consumption,  but  with  the  dawn  of 
renewed  hope,  it  is.  highly  important  for  them  to  understand  that  the 
effort  to  regain  health  is  fraught  with  no  slight  degree  of  individual 
responsibility,  and  that  success  may  be  attained  only  through  wisely 
directed  personal  endeavor. 

Consumption,  though  distinctly  subject  to  arrest,  is  by  no  means 
cured  in  all  instances.  If  recognized  early,  the  possiliilities  of  arre.st  are 
surely  present,  but  the  personal  equation,  both  of  the  physician  and 
patient,  must  remain  a  vitally  decisive  factor  in  the  determination  of 
the  final  outcome.  The  opportunities  presented  for  a  complete  ultimate 
recovery  from  pulmonary  tuberculosis  in  individual  cases  scarcely 
warrant  an  assumption  as  to  the  general  or  invariable  curability  of  the 
disease.  Yet  such  a  conclusion,  regardless  of  vitally  important  condi- 
tions, has  become  a  war-cry  of  some  of  the  "  crusaders." 

It  should  be  understood  that  the  term  "  curability  of  tuberculosis"  is 
necessarily  subject  to  considerable  flexibility  in  its  general  application 
and  in  the  interpretation  of  its  meaning.  To  the  public,  the  impression 
has  been  conveyed  that  "cure"  is  synonymous  with  absence  of  sub- 
jective symptoms  and  restoration  of  working  capacity.  To  the  pro- 
fession a  literal  definition  of  "cure"  represents  the  entire  disappearance 
of  physical  and  bacterial  evidences  of  the  disease.  There  is  also  implied 
an  obliteration  of  the  tuberculous  process  through  fibrous  tissue  pro- 
liferation, or  at  least  the  enduring  encapsulation  of  tubercle  bacilli 
within  the  barriers,  which  encompass  the  previous  foci  of  infection.  It  is, 
of  course,  obvious  that  a  large  number  of  cases  fail  to  attain  a  technical 
cure  even  though  all  clinical  manifestations  of  tuberculosis  have  dis- 
appeared. Despite  an  apparent  restoration  of  health  with  resumption 
of  physical  activity  and  usefulness,  the  supposed  recovery  is  not  founded 
upon  a  strictly  anatomic  basis.  By  what  token  may  it  be  assumed 
in  individual  cases  that  the  connective-tissue  formation  is  .sufficiently 
dense  to  prochicc  (ililiterative  focal  contraction  or  to  imprison  effectually 
the  bacilli  withm  ("uciirling  walls?  Clinical  experience  attests  the 
facility  with  whicli,  cvoii  in  the  midst  of  apparent  recovery,  there  is  finally 
secured  an  avenue  of  escape  for  bacilli  through  a  cordon  of  connective 
tissue,  and  their  subsequent  access  to  uninvaded  pulmonary  areas,  or 
the  development  of  metastatic  foci  of  infection  in  other  portions  of  the 
body.  It  is  evident  that  unqualified  statements  addressed  to  the 
public  relative  to  the  general  curability  of  tuberculosis  should  be  care- 
fully avoided  in  order  to  forestall  popular  chstrust  and  misconception. 
Even  in  supposedly  favorable  cases  the  expression  of  precipitate  con- 
clusions regarding  a  successful  issue  should  be  rendered  with  the  utmost 
conservatism,  that  erroneous  ideas  may  not  be  dis.seminated,  and  that 
individuals  may  not  be  doomed  to  eventual  disappointment. 

Some  observers  have  seen  fit  to  exalt  the  practical  utility  of  certain 
therapeutic  agencies  to  a  point  far  beyond  their  due  value.  Others 
have  deigned  to  renounce  in  toto  the  benefits  accruing  from  methods 
of  undoubted  efficacy.  A  just  and  well-proportioned  estimate  of  the 
true  importance  attaching  to  the  many  phases  of  therapeutic  effort 
is  entertained  by  comparatively  few  physicians  presuming  to  direct 
the  destinies  of  pulmonary  invalids.  It  is  believed  that  the  best  inter- 
ests of  the  consumptive  are  subserved,  if  there  l)e  accorded  by  the 
medical  attendant  a  recognition  of  the  importance  of  the  following 
general  principles  of  management. 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


PRINCIPLES  OF  MANAGEMENT 

The  existing  status  of  medical  opinion  regarding  the  rational  manage- 
ment of  tuberculosis  has  been  stated  to  be  somewhat  unique,  on  account 
of  the  considerable  lack  of  uniformity  exhibited  in  the  way  of  thera- 
peutic effort.  This  appears  all  the  more  remarkable  in  view  of  the 
fact  that  the  present  consensus  of  opinion  among  all  qualified  observers 
relates  solely  to  the  consideration  of  outdoor  life,  rest,  superalimentation, 
and  constant  supervision  as  the  all-important  elementary  factors. 
It  is  difficult  to  understand  how  there  can  exist  such  witlely  differing 
interpretations  of  the  a]3plication  of  these  basic  principles  as  to  permit 
the  resulting  divergent  methods  of  practice,  where  harmony  of  thought 
and  action  might  reasonalily  be  anticipated. 

It  is  recognized  that  pulmonary  mvalids  as  a  class  demand,  upon  the 
merits  of  their  condition,  the  fullest  conception  of  an  intelligent  system 
of  management.  This  may  be  attained  only  through  a  detailed  elabor- 
ation of  underlying  principles,  subject  to  modification  according  to  pecu- 
liar individual  needs.  From  numerous  sources,  however,  there  is  ad- 
vanced, with  perfect  integrity  of  motive,  the  indorsement  of  several 
distinctive  methods  of  treatment  which  appear  unalterably  opposed  to 
one  another.  It  goes  without  saying  that  a  more  or  less  partizan  appreci- 
ation of  their  comparative  merits  is  de^•eloped  by  the  immediate  en%i- 
ronment  and  .special  opportunities  of  the  olxserver.  Thus  is  to  be 
explained  the  repudiation  of  the  advantages  of  climatic  change  for  any 
case,  or  the  advocacy  of  several  totally  differing  localities  for  nearly 
all  classes  and  conditions.  In  like  manner  is  noticed  the  strenuous 
insistence  by  some  upon  a  rigid  disciplinary  regime  within  a  closed 
sanatorium,  as  applicable  to  all  cases  of  consumption,  regardless  of 
many  vitally  important  considerations,  and  at  the  same  time  an 
equally  enthusiastic  indorsement  by  others  of  the  advantageous  con- 
ditions rendered  possible  at  home.  Unfortunately,  the  picture  is  some- 
times painted  in  its  most  dismal  colors  by  ardent  opponents.  The 
invalicl  in  the  mournful  contemplation  of  banishment  to  a  distant 
clime,  incarceration  within  the  walls  of  an  institution  for  consumptives, 
or  seclusion  upon  his  back  porch,  and,  perhaps,  in  an  unsightly  yard, 
may  often  w^onder  which  fate  can  possess  the  least  terror. 

It  does  not  necessarily  follow  that  because  one  of  these  methods 
is  rational  in  certain  instances  that  the  remainder  are  necessarily 
inapplicable  to  other  cases.  Manifesth%  each  has  much  of  merit, 
according  to  the  individual  conditions  imposed,  and  through  the 
exercise  of  an  intelligent  discrimination  on  the  part  of  the  medical 
adviser  may  be  utilized  for  the  material  aid  of  an  appropriate  class. 

Irrespective  of  the  particular  plan  pursued,  it  is  of  the  utmost 
importance  to  remember  that  the  efficacy  of  all  therapeutic  procedures 
is  directl.y  dependent  upon  their  power  to  augment  the  inherent  resisting 
forces  of  the  individual.  The  natural  constructive  processes  are  stimu- 
lated only  by  measures  leading  to  consrrvntion  of  strength.  This,  then,  is 
the  true  fundamental  princijMe  underlying  all  general  therapeutic  agencies 
in  the  effort  to  secure  arrest  of  the  tuberculous  infection.  The  accumu- 
lation of  a  substantial  reserve  in  strength  is  known  to  take  place  through 
the  influence  of  increased  nutrition  and  a  diminished  expenditure  of 
physical  energy.  These  factors  in  the  problem  of  management  are 
utilized  by  an-  intelligent  regulation  of  the  mode  of  life.     Another  feature 


REGARD    FOR    INFINITE    DETAIL  615 

of  essential  importance  is  the  variation  of  individual  adaptability, 
which  imposes  the  necessity  of  a  critical  differentiation  of  cases.  Con- 
ceding that  each  case  is  a  law  unto  itself  and  must  be  adjudged  solely 
upon  the  intrinsic  merits  of  its  many  component  factors,  it  appears 
that  a  preconception  of  fixed  ideas  as  to  the  management  of  consump- 
tion must  give  way  to  a  just  recognition  of  the  valid  and  established 
claims  of  several  methods.  The  application  of  the  various  principles  of 
treatment  to  an  individual  constitutes  a  responsible  trust,  the  satis- 
factory fulfilment  of  which  can  be  afforded  only  through  a  sufficient 
appreciation  of  its  true  character.  The  cardinal  features  to  be  rigidly 
observed  in  the  management  of  all  cases  consist  of:  (1)  Regard  for 
infinite  detail;  (2)  adjustment  of  physical  or  nervous  effort;  (3)  enforce- 
ment of  an  open-air  existence;  (4)  regulation  of  diet. 


CHAPTER  XC 
REGARD  FOR  INFINITE  DETAIL 

The  first  great  requisite  for  rational  treatment  consists  not  only 
of  a  careful  preliminary  investigation  of  all  phases  of  the  disease,  his- 
toric, symptomatic,  and  physical,  but  also  a  diligent  study  of  all  factors 
pertaining  to  the  patient,  i.  e.,  temperamental,  financial,  domestic,  and 
social.  Only  through  such  means  may  the  clinician  hope  to  arrive  at 
definitely  correct  conclusions  concerning  the  manner  of  applying  the 
principles  of  treatment  to  the  best  possible  advantage.  It  is  not  the 
most  complete  interpretation  of  a  single  feature,  no  matter  how  impor- 
tant, that  is  to  accomplish  the  best  results.  Neither  are  these  to  be 
obtained  by  the  most  radical  conception  of  several  thoroughly  accepted 
principles,  if  at  the  obvious  expense  of  remaining  factors,  perhaps  not 
as  well  recoi^uizcd,  yet  entirely  pertinent  to  the  invalid  in  question.  The 
fullest  measuK  nt  mk  i ess  in  management  is  to  be  secured  only  by  the 
wisest  possihli  (innijiiiHj  of  all  the  favorable  influences  pertaining  to 
the  case.  This  imposes  an  obligation  for  painstaking  detail,  and 
necessitates  a  vast  amount  of  study  regarding  the  special  requirements 
in  each  instance. 

Personal  effort  directed  to  a  critical  analysis  of  all  the  phases  of 
each  case  is  absolutely  essential  in  order  to  afford  not  only  a  wise  pre- 
liminary guidance,  but  also  to  facilitate  subsequently  a  continued  adap- 
tation of  the  consumptive  to  a  projicr  ('iniinmncnt.  Thoughtful  study 
and  alert  vigilance  must  be  mainlaincd  ilirou^lidut  the  entire  period 
of  observation,  in  order  to  provide  such  iiioile  of  life  and  surroundings 
as  are  especially  appropriate  to  changing  conditions,  and  in  harmony 
with  the  varying  needs  of  the  patient. 

Following  a  review  of  the  clinical  history  and  an  exhaustive  exami- 
nation of  the  chest,  it  is  my  practice  to  make  a  brief  report  of  the  con- 
dition, and  tn  oliii  such  reassurance  as  is  consistent  with  the  facts  and 
seems  advisuMe  iicjiu  lirst  impressions,  declining,  however,  to  grant  a 
detailed  advisory  statement  until  after  the  urine  and  sputum  have  been 
examined.   This  plan  of  procedure  permits  not  only  precise  clinical  infor- 


616  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

mation  regarding  some  important  phases  of  the  case,  but,  what  is  more 
important,  affords  not  less  than  twenty-four  hours'  delay,  during  which 
time  its  many  aspects  may  be  reviewed. 

It  is  desirable,  in  the  majority  of  instances,  to  transmit  to  the  patient 
and  family  some  intelligent  idea  as  to  the  natui'e  of  the  disease  and  the 
manner  in  which  it  is  hoped  to  secure  arrest.  In  plain  unequivocal 
language,  the  information  shoidd  be  conveyed  as  to  the  overwhelming 
importance  of  the  condition  and  the  necessity  of  implicit  obedience  to 
detailed  instructions.  In  general  a  guardedly  favorable  prognosis  should 
be  rendered,  thus  offering  sufficient  encouragement  to  insure  faithful, 
earnest  cooperation.  The  degree  of  reassurance  to  be  extended  shoukl 
be  carefully  adjusted  by  the  clinician  in  accordance  with  the  tempera- 
mental proclivities  of  the  patient.  The  attitude  of  the  phy.sician  toward 
the  pulmonary  invalid,  who  is,  as  a  rule,  very  susceptible  to  suggestion, 
should  vary  materially  with  the  requirements  of  the  intlividual  case.  The 
vital  thought  ever  to  be  borne  in  mind  is  the  fact  that  the  extent  of 
tuberculous  infection  is  often  of  less  importance  than  the  temperamental 
characteristics  of  the  tuberculous  patient. 

A  perfunctory  recommendation  of  conventional  routine  measiu-es  of 
treatment  is  of  but  little  avail,  if  uninspired  by  a  genuine  devotion  to 
the  well  being  of  the  invalid.  As  a  general  ride,  the  imparting  of  advice 
should  be  accompanied  by  the  exercise  of  consummate  tact  in  its  adapta- 
bility and  manner  of  presentation.  Thus  the  personal  equation  of  the  phy- 
sician becomes  a  highly  important  factor,  often  of  greater  moment  than 
skill  in  diagnosis,  knowledge  of  the  disease,  or  familiarity  with  motlein 
methods  of  phthisiotherapy.  In  view  of  the  pronounced  individual 
peculiarities  often  exhibited  by  pulmonar}'  invalids,  the  value  of  an 
intelligent  dircciiim  iiitlncnce  is  almost  beyond  description.  Alcoholic 
dissipation  and  cither  i-\i(>sses  should  be  controlled  by  stern  admonition; 
foolish  optimism,  umluc  exaltation  of  spirits,  and  frivolity,  by  kindly, 
forcible  restraint;  mental  (Icprcssidn  .'ind  nervous  irritability  by  con- 
stant sustaining  hope  and  (■iicoiira^riucnt. 

Above  all,  it  is  important  to  make  clear  that  a  large  portion  of  the 
credit  or  responsibility  for  ultimate  results  must  rest  directly  upon  the 
patient,  the  prospects  of  a  successful  termination  being  greatly  enhanced 
by  strict  conformity  to  instructions.  It  should  be  emphasized  that,  for 
the  time  being,  the  invalid  is  engaged  in  a  momentous  undertaking  of 
infinitely  greater  magnitude  than  the  pursuit  of  business  or  indulgence 
in  social  enjoyment.  Patients  should  be  taught  that  the  period  of  treat- 
ment is  the  vitally  important  era  of  their  existence,  and  that  no  reason- 
able sacrifice  is  too  great,  provided  progress  toward  recovery  is  thereby 
facilitated.  They  should  be  informed  that  the  duration  of  the  period 
of  medical  observation  is  necessarily  prolonged  and  that,  in  the  verbiage 
of  the  legal  profession,  "  Time  constitutes  the  essence  of  the  proposition." 
It  is  usually  well  to  acquaint  invalids  with  the  fact  that  their  path  may 
be  beset  wth  difficulties,  and  that  the  journey  to  recovery  is  attended 
by  trials  to  their  patience,  endurance,  and  fortitude,  but  that  the  hard- 
ships are  surmountable  by  dint  of  courage,  wise  guidance,  and  indomita- 
ble perseverance.  In  the  effort  to  impress  trifling  young  men  with  the 
gravity  of  the  situation  I  sometimes  have  made  use  of  the  following 
homely  illustration:  "You  are  engaged  in  an  arduous  conflict  with 
a  most  formidable  antagonist.  Your  opponent  is  worthy  of  your 
most  strenuous  efforts,  and  will  be  quick  to  take  advantage  of  the 


REGARD    FOR    INFINITE    DETAIL  617 

slightest  opening  to  inflict  a  serious  blow.  The  struggle  is  no  four-  or 
six-round  contest,  but  the  fight  is  destined  to  continue  to  a  finish.  There 
can  be  no  such  thing  as  a  draw.  Either  your  enemy  will  be  finally  van- 
quished or  pulmonary  tuberculosis  will  have  attained  the  victory  over 
you.  It  is  for  you  alone  to  decide  whether  you  will  enter  the  arena 
with  a  determination  to  succeed  and  with  the  exercise  of  eternal  vigilance 
be  prepared  to  withstand  successfully  the  onslaughts  of  an  unrelenting 
foe." 

It  is  often  expedient  to  inform  the  invalid  concerning  the  signal 
advantage  possessed  by  virtue  of  the  natural  powers  of  resistance  to 
tuberculous  infection.  It  is  usually  well  to  make  clear  that  there  is 
no  special  method  of  treatment,  and  that  the  position  of  the  medical 
attendant  is  that  of  counsellor,  to  guard  against  blunders  and  indis- 
cretions, and  that  strict  compliance  with  instructions  is  a  sine  qua  non 
to  success.  I  have  found  it  desirable  in  many  instances  to  explain 
in  a  simple  and  conci.se  way  the  manner  in  which  the  inherent  con- 
structive forces  of  the  individual  are  capable  of  producing  arrest. 
Among  intelligent  invalids  I  have  found  this  of  practical  advantage  in 
the  stimulation  of  renewed  efforts,  and  in  the  reassurance  conve.yed  as 
to  the  rationale  of  the  treatment.  Words  to  the  following  effect  have 
usually  been  found  satisfactory  for  this  purpose.  "  Any  injury  to  the 
surface  of  the  body  attended  by  a  loss  of  substance  is  followed  by  the 
formation  of  new  connective  tissue,  which  differs  markedly  in  structure 
from  the  adjacent  parts.  The  scar  tissue  which  results  is  dense,  tough, 
fibrous,  and  contractile.  The  formation  of  this  tissue,  which  has  no 
analogue  in  health,  is  nature's  method  of  repairing  damage  in  the  various 
organs  and  soft  parts  of  the  body.  Consumption  is  a  disease  produced 
by  a  certain  microorganism,  which,  upon  gaining  entrance  to  the  lungs, 
incites  characteristic  tissue  change.  Tiny  elementary  tubercles  are 
formed,  several  of  which  become  confluent  and  unite  to  produce  definite 
nodules.  One  of  the  essential  characteristics  of  these  tubercles  is  the 
tendency  toward  central  degeneration,  caseation,  and  disintegration.  As 
this  takes  place,  the  proce.ss  of  repair  becomes  established  in  varying 
degree  in  different  individuals.  The  two  processes  continue  simultane- 
ously, and  a  race  is  established  between  tissue  destruction  and  tisstie 
construction.  If  in  your  fight  with  tuberculosis  you  possess  sufficient 
vitality  to  manufacture  new  tissue  more  rapidly  than  the  lung  tissue  is 
destroyed,  you  win.  If,  on  the  other  hand,  your  efforts  toward  the 
making  of  scar  tissue  are  enfeebled,  the  reverf5e  is  inevitable.  The 
measure  of  your  constructive  capacity  is  the  conservation  of  strength, 
which  to  a  great  extent  is  to  be  proportionate  to  your  gain  in  weight  and 
your  rigid  economy  in  the  expenditure  of  bodily  energy.  To  secure 
satisfactory  results  in  your  struggle  with  tuberculosis,  it  is  necessary 
to  attain  a  surplus  of  vital  energy  through  the  influence  of  nutrition. 
This  is  accomplished  as  a  joint  result  of  superalimentation  and  physical 
rest.  It  is  not  altogether  what  you  earn  through  enforced  feeding,  but 
also  what  you  save  by  being  quiet." 

As  a  result  of  this  personal  understanding  of  the  rationale  of  the 
methods  to  be  advised,  it  is  easy  to  conceive  how  much  more  ready 
is  the  acceptance  of  an  enforced  regime,  how  much  greater  confidence 
is  established  between  patient  ancl  physician,  and  to  what  greater 
extent  there  may  be  instituted  mutual  sympathetic  cooperation.  Thus, 
having  instituted  early  relations  of  confidence  and  reciprocal  effort,  the 


618  PROPHYLAXIS,    GENERAL    AND    SPECIFIG    TREATMENT 

physician  is  usually  permitted  with  less  opposition  to  elaborate  ideas 
of  treatment,  which  might  otherwise  be  non-acceptable  to  patient  and 
friends.  In  maintaining  a  responsible  direction  of  the  patient,  the 
clinician  is  repeatedly  confronted  by  the  necessity  of  observing  a  dili- 
gent, painstaking  regard  for  detail. 

It  is  comparatively  simple  to  prescribe  rest,  fresh  air,  and  plenty  of 
good  food,  but  the  obligation  of  the  physician  is  not  discharged  until 
he  personally  provides  such  accommodations  as  wiU  insure  the  proper 
continuous  execution  of  his  directions.  The  surroundings  of  the  patient 
should  be  subjected  to  personal  inspection,  simple  inquiry  relative  to 
the  environment  being  utterly  inadequate  for  the  determination  of  its 
fitness.  Accurate  information  must  be  secured  as  to  the  appropriate- 
ness of  the  location,  the  adaptability  of  the  dwelling  to  the  purposes 
and  needs  of  the  patient,  the  character  of  the  food,  and  the  nature  of 
social  or  recreative  features.  Attention  should  be  specifically  directed 
to  the  occupation,  habits,  financial  status,  domestic  relations,  resources 
for  individual  entertainment  or  diversion,  and  finally  to  the  disposition 
and  degree  of  self-control.  The  management  of  consumptives  is  radi- 
cally different  from  that  of  any  other  class  of  human  beings,  in  view 
of  the  fact  that,  by  virtue  of  their  illness,  there  are  sometimes  exhibited 
decided  changes  of  temperament  and  mental  attitude,  as  described  in 
connection  with  the  General  Symptomatology.  Pulmonary  invalids 
constitute  a  class  decidedly  unique  and  peculiar  to  themselves,  demand- 
ing of  the  medical  attendant  the  exercise  of  the  greatest  tact,  judgment, 
and  skill  that  is  required  in  all  the  domain  of  medicine. 

It  unfortunately  happens  in  many  cases  that  the  accompanying 
members  of  the  family  exhibit  traits  of  character  and  disposition  which 
add  vastly  to  the  trials  and  vexations  of  the  physician.  While  many 
patients  have  literally  committed  suicide  through  their  own  folly  and 
indiscretions,  others  are  sacrificed  through  the  perversity,  ignorance, 
and  delusions  of  their  immediate  relations.  Petting,  sympathy,  con- 
dolence, or  indulgence  on  the  part  of  others  constitutes  a  most  serious 
hindrance  to  the  accomplishment  of  best  results.  For  these  reasons 
conspicuous  success  often  attends  complete  segregation  of  the  patient. 
Several  times  I  have  insisted  upon  the  separation  of  little  children  from 
their  parents  for  over  two  years  at  a  time,  and  have  placed  them  under 
the  care  of  trained  nurses  especially  adapteil  to  the  work.  While  this 
may  seem  chfficult  of  execution,  I  have  found  that,  if  properly  presented, 
the  family  are  usually  quick  to  appreciate  the  wisdom  of  such  advice 
and  govern  tlicmschi-  nrcordingly. 

At  no  ;ii;r  :iic  ii.iiii-iits  more  domineering,  wilful,  and  difficult  of 
management  ilum  iu  tlie  neighborhood  of  eighteen,  even  if  confined  to 
the  bed.  I  have  found  the  care  of  such  patients  to  be  made  conspicu- 
ously more  simple  and  effective  if  removed  from  their  parents.  The 
separation  of  husband  and  wife  is  often  expedient  by  reason  of  various 
widely  differing  considerations  in  individual  cases.  In  such  instances 
the  physician  must  possess  the  courage  of  his  convictions  sufficiently  to 
insist  upon  the  removal  of  these  influences  through  such  isolation  as 
may  be  reasonable  and  practicable. 

The  task  of  enforcing  a  proper  regime  varies  witliin  wide  limits. 
It  is  comparatively  easy  to  secure  the  active  cooperation  of  patients 
who  are  intelligent,  phlegmatic  in  temperament,  and  amenable  to  advice, 
but  it  is  the  experience  of  those  who  are  brought  in  contact  with  the  vari- 


ADJUSTMENT    OF    PHYSICAL    AND    NERVOUS    EFFORT  619 

ous  stages  and  conditions  of  pulmonary  tuberculosis  that  all  patients  do 
not  conform  to  this  class.  When  to  the  care  of  the  pulmonary  invalid 
there  are  added  the  difficulties  arising  from  the  peculiarities  and  per- 
versions of  judgment  of  members  of  the  familj',  it  is  easy  to  appreciate 
that  successful  management  necessitates  such  a  degree  of  patience, 
determination,  and  attention  to  detail  as  almost  to  constitute  a  form  of 
genius.  The  extent  to  which  this  endowment  is  posse.ssed  by  the  medical 
attendant  is  responsible  in  large  measure  for  the  success  which  may  be 
expected  to  attend  his  efforts. 


CHAPTER   XCI 
ADJUSTMENT  OF  PHYSICAL  AND  NERVOUS  EFFORT 

The  regulation  of  exertion  constitutes  a  cardinal  principle  of  treat- 
ment, applicable  to  all  cases  of  tuberculosis.  The  processes  of  repair 
in  general  are  stimulated  by  the  enforcement  of  appropriate  rest.  For 
the  accomplishment  of  best  results  it  is  imperative  to  minimize  the 
demands  upon  the  nervous  forces,  as  well  as  upon  the  physical  strength. 
Conservation  of  energy  in  every  conceivable  manner  should  be  the 
watchword  imparted  to  the  patient,  without  which  the  onward  progress 
toward  recovery  is  interrupted  by  the  interposition  of  serious,  if  not 
insurmountable,  obstacles. 

Rest  for  pulmonary  invalids  must  be  accepted  as  a  purely  relative 
term,  varying  in  its  interpretation  from  absolute  immobilization  in  the 
recumbent  position  to  moderate  degrees  of  physical  exercise.  The  im- 
portant desideratum  is  the  avoidance  of  fatigue  from  any  cause,  whether 
physical,  nervous,  or  mental.  Fatigue  necessarily  develops  at  varying 
times,  and  in  vastl}'  differing  degree,  according  to  the  condition  of  indi- 
vidual patients.  A  restrained  physical  activity,  which  in  some  persons 
constitutes  comparative  rest,  may  represent  in  others  an  unwarranted 
excess.  In  the  same  way  reading,  study,  conversation,  card-playing, 
knitting,  eml^roidery,  or  other  handiwork  may  offer  healthful  diverting 
occupation  to  some,  but  become  acutely  exhausting  to  others,  through 
the  entailed  mental  effort  or  nervous  excitement. 

Rest  may  be  regarded  as  eminently  desirable  for  pulmonary  invalids 
as  a  class,  but  the  paramount  consideration  relates  to  an  accurate 
determination  of  the  extent  to  which  this  should  ajiply  to  individuals. 
The  intelligent  .'ind  cMVciive  regulation  of  the  exciiion  :ii>iii(i]iriate  for 
a  given  consuiiipti\c.  tliuuiih  attended  at  times  wiili  ilic  '_:icatest  diffi- 
culty, perhap.s  truiiscciids  in  importance  all  other  lc:i,iiiivs  dl  treatment. 
Fresh  air  and  superalimentation  have  long  been  recognized  as  valuable 
therapeutic  factors,  but  practical  experience  leads  to  the  belief  that  the 
adjustment  of  physical  and  nervous  effort  is  even  more  important. 

While  the  necessil\-  Im-  judiciims  circumspection  regarding  exercise 
obtains  even  among  imipicm  ca-c-.  ilic  role  of  rest  as  a  therapeutic 
measure  of  the  first  niagiutmli'  is  f<i>(M'i;dly  emphasized  in  connection 
with  far-advanced  patients.  Open  air,  which  admittedly  is  indispen- 
sable to  all  stages  and  conditions  of  the  disease,  becomes  in  desperate 


620  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

cases  subordinate  in  importance  to  complete  rest.  Either  one  of  these 
factors,  with  the  sacrifice  of  the  other,  is  of  but  slight  value  to  such 
a  class.  No  matter  how  manj'  the  hours  out-of-doors,  if  attended  by 
fatigue,  each  day  must  be  summed  up  as  a  failure.  In  like  manner 
the  enforced  consumption  of  a  proper  amount  of  food  can  avail  but 
little  if  the  nervous  force  required  for  the  proper  performance  of 
digestion  and  assimilation  is  dissipated  through  the  influence  of  undue 
exercise  or  excitement.  Phj-sical  exertion  must  be  forbidden,  even 
to  the  slightest  extent,  among  far-advanced  consumptives,  not  only 
because  it  produces  exhaustion  and  further  deranges  digestion,  but 
also  on  account  of  its  tendency  to  increase  temperature  elevation 
and  to  excite  hemorrhage.  Duriii-r  the  active  advance  of  the  infection 
the  digestive,  circulatory,  and  respiratory  functions  become  embar- 
rassed more  or  less  by  the  presence  in  the  blood  of  toxins  which, 
formed  in  excessive  amount,  give  rise  to  the  fever  and  other  character- 
istic symptoms  of  sepsis.  It  is  precisel}'  at  such  times  that  the  addi- 
tional burden  imposed  by  physical  exertion  upon  already  overtaxed 
functions  is  productive  of  most  disastrous  results.  Fever,  then,  may 
be  regarded  in  any  stage  of  tuberculosis  as  an  unfailing  indication  for 
a  mandatory  insistence  upon  complete  rest. 

By  absolute  rest  is  meant  the  actual  relaxation  of  the  patient  in  bed 
during  the  entire  twenty-four  hours.  A  temperature  in  the  neighbor- 
hood of  102°  F.  at  any  hour  of  the  day  suggests  the  wisdom  of  main- 
taining the  recumbent  position  for  an  indefinite  period,  the  patient  not 
being  permitted  to  rise  until  the  fever  has  materially  abated.  An 
afternoon  temperature  of  100°  F.  or  thereabouts,  despite  the  absence 
of  fever  earlier  in  the  day.  demands  a  decided  restriction  of  physical 
effort.  Under  such  circumstances  it  is  expedient  to  enjoin  complete 
rest  in  bed  at  least  during  the  period  of  temperature  elevation.  If  the 
fever  recedes  to  normal  during  the  early  e\-ening,  it  is  sometimes  well 
to  allow  the  patient  to  sit  up  for  a  short  time  before  retiring  for  the 
night. 

In  general,  patients  exhibiting  a  temperature  of  99f  °  F.  at  any  time 
of  the  day  should  be  forbidden  to  indulge  in  walking  as  a  form  of  exer- 
cise, as  in  such  cases  the  fever  is  frequently  increased  even  by  a  short, 
slow-  walk.  In  this  connection  it  is  important  to  discriminate  between 
a  temporary  elevation  of  temperature  taken  in  the  rectum  shortly  after 
exercise  is  concluded,  and  the  fever  w'hich  may  appear  after  an  interval 
of  rest.  It  has  been  ascertained  that  a  considerable  physiologic  rise  of 
temperature  in  health  may  follow  prolonged  or  unusually  severe  exercise, 
even  moderate  walking  for  a  comparatively  short  time  may  produce 
a  slight  elevation  of  temperature,  which  completely  recedes  after  a  half- 
hour  interval  of  physical  repose.  The  susceptibility  of  pulmonary  inva- 
lids to  temporary  elevations  of  temperature  after  walking  is  much  greater 
than  of  healthy  people.  The  fever  reaction  in  such  cases  is  not  only 
more  marked,  but  of  longer  duration,  the  rise  of  temperature  frequently 
being  sustained  for  manj'  hours  in  spite  of  complete  rest. 

Much  confusion  regarding  the  effect  of  exerci.se  upon  the  body  heat 
may  be  avoided  if  the  temperature  be  taken  in  the  mouth  only  after  a 
period  of  rest.  A  transitorj'  fever  shortly  after  exercise  may  be  detected 
if  the  temperature  is  taken  in  the  rectum,  while  no  indication  of  its  pres- 
ence would  be  afforded  by  the  oral  record.  After  the  lapse  of  a  short 
interval  of  rest,  the  physiologic  elevation  of  temperature,  as  indicated  in 


ADJUSTMENT    OF    PHYSICAL    AND    NERVOUS    EFFORT  621 

the  rectum,  is  found  to  subside,  while  the  fever  of  pathologic  significance 
is  recognized  in  the  mouth  and  remains  persistent  for  several  hours.  It 
thus  appears  that  but  slight  practical  importance  attaches  either  to  the 
oral  or  rectal  temperature  taken  immediatehj  after  exercise,  the  former 
being  fallacious  and  the  latter  ephemeral.  The  development  of  fever,  as 
evidenced  by  the  oral  record,  after  rest  is  an  undoubted  indication  of  the 
immediate  deleterious  effect  produced  by  physical  effort.  For  such 
patients  exercise  should  not  be  again  permitted  until  the  temperature 
has  receded  below  99°  F.  and  remained  practically  normal  for  at  least 
several  days.  When  walking  is  resumed  tentatively,  the  utmost  caution 
should  be  taken  to  guard  against  overexertion.  Upon  the  whole,  fever 
may  be  regarded  as  the  leading  contraindication  for  physical  exercise. 

Complete  rest  in  bed  is  also  demanded  in  the  presence  of  severe 
dyspnea  and  cyanosis,  with  a  weak  and  i-apid  pulse.  As  a  rule,  circula- 
tory or  respiratory  embarrassment  does  not  suggest  as  emphatically 
as  fever  the  imperative  necessity  for  absolute  rest.  In  such  cases,  with- 
out temperature  elevation,  the  indications  point  to  a  considerable  restric- 
tion of  active  physical  effort  with,  sometimes,  under  competent  super- 
vision, the  systematic  employment  of  passive  mo\ements.  Rubbing, 
gentle  massage,  or  resistance  exercise  may  be  utilized  occasionally  to 
promote  capillary  dilatation,  to  equalize  the  circulation,  and  to  develop 
the  heart. 

In  less  desperate  cases,  in  which  the  maintenance  of  the  recum- 
bent position  is  not  warranted,  much  good  may  be  accomplished  in 
selected  cases  by  carefully  adjusted  exercise.  It  is  essential,  however, 
that  the  degree  of  physical  activity  should  be  subject  to  a  judicious 
regulation  and  control.  Through  the  increase  of  appetite,  the  promotion 
of  oxidation  and  elimination,  the  general  tone  of  the  system  is  materially 
improved  and  resistance  correspondingly  increased.  It  should  be 
insisted  that  muscular  development  is  not  the  end  to  be  achieved,  and 
that  exercise  is  of  value  only  in  proportion  as  general  resistance  is  pro- 
moted. Patients  should  be  informed  that  the  accumulation  of  a  reserve 
in  nutrition  and  vital  energy  is  of  vastly  more  importance  than  muscular 
strength  or  powers  of  endurance.  In  selecting  a  form  of  exercise  con- 
sistent with  the  needs  of  a  given  ca.se,  there  is  demanded  of  the  physician 
far  more  than  a  consideration  of  the  physical  condition.  A  feature  of 
no  little  significance  is  the  psychic  element,  which  may  be  taken  advan- 
tage of  through  an  intelligent  inquiry  regarding  the  tastes  of  the  indi- 
vidual. By  this  means  there  may  be  afforded  a  wise  discernment 
regarding  the  appropriateness  and  value  of  various  forms  of  outdoor 
amusement.  For  the  accomplishment  of  the  most  satisfying  results 
in  the  continued  maintenance  of  an  outdoor  regime,  it  is  essential  that 
recreation  be  combined  with  exercise.  Natural  and  acquired  proclivities 
of  individuals  should  form  within  certain  limits  an  important,  if  not  a 
determining,  factor  in  the  character  of  the  phy.sical  cUversion  permitted 
to  pulmonary  invalids.  A  measure  of  the  usefulness  of  any  outdoor 
pastime,  provided  that  this  is  not  subject  to  especial  contraindications, 
and  pursued  in  strict  accordance  with  prescribed  directions,  is  the  degree 
of  actual  enjoyment  afforded.  Correctly  regulated  exercise,  if  adapted 
to  the  inclinations  of  the  invalid,  is  diverting  in  nature  and  correspond- 
ingly healthful,  while  physical  effort  without  recreation,  no  matter  how 
perfectly  adjusted,  remains  but  work,  and  hence  less  advantageous. 

Walking  in  the  open  air  is  the  simplest,  safest,  and  usually  most 


622  PROPHYLAXIS,    GEXERAL    AND    SPECIFIC    TREATMENT 

acceptable  form  of  exercise  for  pulmonary  invalids.  This  appears  capa- 
ble of  an  easy  and  accurate  regulation,  but  such  is  not  always  the  case. 
The  paramount  thought  is  to  avoid  the  slightest  fatigue,  shortness  of 
breath,  or  cardinc  /kiI pildlion.        -~ 

It  is  essential  ihat  the  invalid  should  be  permitted  to  resume  a  posi- 
tion of  rest  not  alici-  1k'  has  experienced  fatigue,  hut  before.  He  should 
not  walk  until  he  is  tired  and  then  attempt  to  return,  but  should  arrive 
upon  the  porch  before  this  sensation  is  felt.  If  fatigue  is  experienced  as 
a  result  of  the  walk,  and  particularly  if  peisistent  after  a  rest  of  ten  or 
fifteen  minutes  upon  the  couch,  definite  harm  has  been  inflicted.  While  it 
is  apparent  theoretically  that  the  duration  of  the  walk,  the  direction,  the 
time  of  day  or  night,  and  even  the  company  should  be  definitely  outlined 
by  the  physician,  such  a  degree  of  supervision  is  not  always  practicable. 
Furthermore,  the  utmost  difficulty  attends  anything  like  a  correct  esti- 
mate of  the  individual  capabilities  at  different  times.  Invalids  exhibit 
a  decided  variance  in  the  effect  produced  by  a  fixed  amount  of  exer- 
cise even  upon  successive  days.  The  extent  of  the  walk  appropriate 
for  the  consumptive  can  be  tletermined  only  by  a  comprehensive  regard 
for  much  detailed  data.  While  it  is  comparatively  easy  to  prescribe 
perfunctorily  the  exact  distance,  the  hour,  the  course,  and  even  the  pace, 
such  a  refinement  of  treatment  savors  more  of  ignorance  and  imposture 
than  of  clinical  exactitude. 

From  a  purely  practical  standpoint  the  conviction  has  been  forced  that 
while  rigid  supervisory  guidance  in  the  matter  of  exercise  falls  properly 
within  the  province  of  the  physician,  the  detailed  application  of  the  prin- 
ciples of  rest  must  be  left  to  some  extent  to  the  intelligence,  obedience,  and 
judgment  of  the  patient.  The  enforcement  of  a  strict  advisory  regime 
should  not  necessarily  imply  that  pulmonary  invalids  be  compelled  to 
resolve  themselves  into  unthinking  automatons  whose  very  existence 
shall  be  controlled  by  autocratic  dictation.  After  an  elaboration  of  the 
principles  upon  which  the  determination  of  appropriate  exercise  is  based, 
an  appeal  to  the  reason  and  understanding  of  the  consumptive  serves  to 
establish  relations  of  confidence  and  good  feeling  and,  in  addition,  inspires 
the  invalid  with  a  sense  of  his  personal  responsibility.  To  intelligent  inva- 
lids, devoted  to  the  cause  in  which  they  are  forced  to  enlist,  the  advisory 
direction  should  not  partake  of  an  arbitrary  character.  In  view  of 
the  chfficulty  attending  the  accurate  differentiation  of  individual  capa- 
bilities and  requirements,  it  not  infrequently  happens  that  the  patient, 
even  better  than  the  medical  adviser,  is  enabled  to  appreciate  the  effect 
of  prescribed  exercise,  and  to  judge  approximately  concerning  the  pro- 
priety of  its  repetition.  JIany  patients  who  have  been  suitably  in- 
structed concerning  the  dangers  of  overexertion,  quickly  recognize  its 
deleterious  effect,  and  learn  to  exercise  a  judicious  regard  for  their  own 
welfare  in  the  matter  of  physical  activity.  The  physician  should  insist 
upon  comparative  rest  for  all  ambulant  cases,  and  admonish  earnestly 
that  general  directions  in  this  respect  be  scrupulously  oboycd.  Definite 
commands  well  within  the  limits  of  safety  must  I'c  i--uril  to  the  ignor- 
ant, headstrong,  and  frivolous.  Consumptives  who  arc  wilful  or  vicious 
are  wont  to  disobey  mandatory  instructions,  no  matter  liow  emphatically 
or  definitely  given. 

It  is  highly  essential  that  the  beginning  walk  for  convalescent  inva- 
lids should  be  short,  slow,  and  upon  level  ground.  With  increasing 
strength  greater  indulgence  may  be  extended  from  time  to  time,  pro- 


ADJUSTMENT    OF    PHYSICAL    AND    NERVOUS    EFFORT  623 

vided  no  unfavorable  effects  are  noted.  In  the  interests  of  safety  it  is 
well  to  inculcate  in  the  minds  of  patients  the  conviction,  that  exercise 
does  not  constitute  an  especially  important  desideratum  in  the  effort  to 
secure  arrest,  but  rather  represents  an  indulgence  to  be  gi'anted  in 
selected  cases  with  wise  discrimination.  Prolonged  walks  and  arduous 
hill-climbing  should  be  interdicted,  even  to  patients  well  upon  the  road 
to  recovery.  In  general  issue  is  taken  with  the  recommendation  of 
graduated  walks  upon  upward  inclines,  a  practice,  unfortunately,  still 
somewhat  in  vogue.  While  this  procedure  in  some  instances  produces 
beneficial  effects  in  the  development  of  the  heart  and  impi-ovement 
of  the  respiratory  function,  untoward  results  from  such  strenuous  exer- 
tion are  all  too  frequently  noted.  These  consist  not  only  of  general 
fatigue,  breathlessness,  and  cardiac  palpitation,  infallible  criteria  of  the 
unfavorable  effect  of  exercise,  but  also  of  the  occasional  intercurrence 
of  pulmonary  hemorrhage  or  pneumothorax. 

The  character  of  the  pulse  is  often  an  important  guide  to  the  regula- 
tion of  the  walk.  Marked  rapidity,  weakness,  or  imtability  clearly 
indicate  the  necessity  of  continuous  enforced  rest.  It  is  the  custom 
of  some  internists  to  attempt  a  reduction  in  the  pulse-rate  through 
a  graduated  system  of  active  methodic  exercises.  An  experience  in 
the  higher  altitudes  leads  to  the  belief  that  such  measures,  no  matter 
how  carefully  conducted,  are,  as  a  rule,  distinctly  deleterious,  and 
that  overfrequency  of  the  heart  demands,  in  the  majority  of  instances, 
insistence  upon  complete  rest. 

Patients  who  are  considerably  exhausted  by  disease  usually  become 
readily  amenable  to  control  as  regards  the  extent  and  character  of  their 
physical  exercise.  With  beginning  subsidenc^e  of  subjective  symptoms 
a  continued  ready  compliance  with  instructions  is  often  manifested, 
but  with  returning  strength,  increase  of  vitality,  and  buoyancy  of  spirits 
an  overconfidcnce  in  the  physical  capabilities  and  endurance  is  naturally 
engendered.  At  this  time  it  is  often  exceedingly  difficult  to  impress 
the  patient  with  the  fact  that  recovery  has  not  yet  taken  place.  The 
invalid  should  be  made  to  realize  that  despite  the  complete  disappear- 
ance of  all  clinical  manifestations,  an  improved  nutrition  and  the  con- 
sciousness of  physical  strength,  there  still  remain  definite  pathologic 
changes  in  the  pulmonary  tissues.  Far  from  permitting  the  assumption 
that  a  cure  has  been  permanently  established,  it  is  expedient  to  designate 
the  condition  as  a  quiescent  tuberculous  infection  undergoing  arrest. 
The  further  evolution  of  a  complete  enduring  recovery  is  dependent 
largely  upon  the  degree  to  which  the  patient  confoi-ms  to  wise  cdunsels 
regarding  conservation  of  strength.  Evni  llic  physician  :i,1  lliis  stage 
is  likely  to  deceive  himself  by  a  sense  of  false  seen  lity,  and,  yicldin.ii  (d  tiie 
blandishments  and  confident  assertions  of  the  patient,  may  permit  a  lax- 
ity in  the  supervisory  control,  .seriously  jeopardizing  the  interests  of  the 
apparently  cured  consumptive.  There  can  be  but  little  ultimate  satis- 
faction to  the  physician  in  having  his  patient  improve  unless  he  succeeds 
in  bringing  about  a  final  arrest  of  the  tuberculous  process.  To  this  end 
no  therapeutic  measure  is  of  more  undoubted  efficacy  than  a  continued 
economi)  in  the  expenditure  of  physical  and  nervous  energy  long  after  the 
disappearance  of  all  clinical  inanifestations  of  the  disease. 

An  interesting  and  somewhat  remarkable  difference  of  opinion  is 
entertained  among  medical  observers  with  reference  to  the  practical 
utility  of  pulmonary  gymnastics.     Some  there  are  who  advocate  deep 


624  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

breathing  exercises  as  of  striking  therapeutic  value,  while  others 
entirely  discountenance  such  measures  as  fraught  with  definite  ele- 
ments of  danger.  Strikingly  different  arguments  are  advanced  by 
those  advocating  and  opposing  pulmonary  gymnastics  for  consump- 
tives. The  former  assert  that  an  underlying  principle  of  treatment  is 
exercise  of  the  tuberculous  lungs,  in  order  to  promote  their  expansion, 
circulation,  and  nutrition,  thus  adding  to  the  aeration  of  the  blood, 
the  elimination  of  carbon  dioxid,  and  the  resistance  of  the  entire 
organism.  It  is  the  contention  of  others  that  a  cardinal  feature  to  be 
observed  is  the  maintenance  of  rest  for  the  tuberculous  kmg.  as  well  as 
of  the  tuberculous  individual,  in  order  to  avoid  an  extension  of  the 
infection  into  new  pulmonary  areas,  and  to  avert  the  development  of 
pneumothorax  or  pulmonary  hemorrhage  through  unusual  activity 
and  depth  of  the  respiratory  excursions.  Clinical  evidence  is  not 
lacking  to  sustain  the  claims  of  those  entertaining  views  diametrically 
opposed  to  each  other.  The  beneficial  effects  obtained  in  the  higher 
altitudes  afford  a  presumptive  confirmation  of  the  advantages  derived 
from  an  increased  activity  of  the  respiratory  function,  although  in  such 
resorts  other  factors  share  in  the  production  of  favorable  results.  Upon 
the  other  hand,  attention  has  been  called  in  previous  chapters  to  the  not 
infrequent  improvement  noted  during  compression  of  lung  bj'  a  mod- 
erate pleural  effusion. 

A  review  of  the  available  data  discloses  the  fact  that  an  active 
expansion  of  affected  pulmonary  areas  is  of  undoubted  value  in  a  large 
proportion  of  cases,  that  compression  of  affected  lung  is  useful  in 
others,  but,  above  all,  that  artificial  methods  of  producing  either  vesicu- 
lar dilatation  or  compression  are  frequently  attended  by  possibilities 
of  danger.  While  their  employment  in  some  instances  is  followed  by 
results  of  a  gratifying  nature,  in  others  the  effect  is  eminently  injuri- 
ous or  of  doubtful  utility. 

It  is  clear  that  the  scope  of  pulmonary  gymnastics  is  subject  to  con- 
siderable limitation,  and  that  belief  in  their  efficacy  or  harmfulness  varies 
according  to  the  environment,  personal  experience,  and  point  of  view  of 
medical  observers.  It  is  apparent  that  if  unfortunate  consequences  are 
to  be  avoided  from  the  employment  of  deep  breathing  exercises,  judici- 
ous discrimination  must  be  exercised  in  their  individual  application. 
Pulmonary  gymnastics  are  undoubtedly  of  decideil  benefit  in  the  pres- 
ence of  certain  non-tuberculous  changes  in  the  lung  and  pleura.  It  is 
important  to  distinguish  clearly  between  the  chronic  anatomic  con- 
ditions present  in  such  cases  and  the  acute  pathologic  processes  incident 
to  pulmonary  tuberculosis.  In  the  midst  of  extensive  pleural  thickening 
with  marked  fibroid  change,  incomplete  expansion  of  lung  following 
operation  for  empyema  or  pneumopyothorax,  delayed  or  partial 
resolution  following  pneumonia,  or  pleuritic  adhe.sions  subsequent  to 
an  effusion,  it  is  important  to  restore  the  respiratory  function  as  fully 
as  possible.  The  indications  then  point  to  the  enforcement  of  vigorous 
breathing  exercises  in  order  to  promote  expansion  of  the  already 
crippled  lung,  and  incidentally  to  enhance  the  compensatory  activity 
of  the  non-damaged  pulmonary  areas.  There  is  no  valid  reason  why 
the  existence  of  similar  conditions  among  tuberculous  patients  should 
not  suggest  the  expediency  of  the  same  procedures,  provided  important 
contraindications  do  not  exist.  While  routine  recourse  to  the  employ- 
ment of  pulmonary  gymnastics  for  consumptives  should  be  unquali- 


ADJUSTMENT    OF    PHYSICAL    AND    NERVOUS    EFFORT  625 

fiedly  condemned,  carefully  supervised  breathing  exercises  have  proved 
to  be  eminently  beneficial  in  the  partial  restoration  of  the  respiratory 
function  resulting  from  the  above-mentioned  complications. 

The  practice  of  forcible  breathing  among  active  advanced  cases  offers 
but  little  if  any  advantage,  and  much  in  the  way  of  disastrous  results. 
Among  the  unfortunate  sequelae  sometimes  observed  are  the  further 
extension  of  the  tuberculous  infection,  the  gradual  production  of  gen- 
eral emphysema,  the  development  of  pneumothorax  from  rupture  of 
pleura,  the  onset  of  pulmonary  hemorrhage,  and,  rarely,  an  aspiration 
pneumonia.  The  practice  of  recommending  deep  breathing  exercises 
to  pulmonary  invalids  should  be  discredited  whenever  the  subjective 
manifestations  and  physical  signs  portray  an  active  or  extensive 
tuberculous  infection,  especially  if  there  exist  acute  inflammatory 
complications,  pulmonary  excavation,  recurring  hemorrhages,  fever, 
irritable  pulse,  or  exhaustion. 

The  advocates  of  pulmonary  gymnastics  have  adopted  various 
methods  of  putting  deep  breathing  exercises  into  effect,  with  and  with- 
out supplemental  movement  of  the  arms,  changes  of  posture,  and  exer- 
cises of  the  body.  Deep  forcible  respirations  may  be  practised  with 
the  patient  in  the  erect  or  reclining  position  and  during  the  act  of 
walking.  It  does  not  appear  to  be  essential  that  the  inspiration 
should  be  taken  through  the  nose,  as  some  have  maintained,  but  it  is 
important  that  the  breath  should  be  held  for  a  few  moments.  The 
expiration,  while  not  violent,  should  be  as  complete  as  possible  in 
order  to  minimize  the  amount  of  residual  air.  Some  aid  is  secured  by 
bringing  into  play  the  voluntary  muscles  of  expiration.  To  this  end  the 
arms  may  be  raised  to  the  horizontal  position  or  over  the  head  in 
inspiration,  to  be  dropped  quickly  at  the  time  of  expiration.  It  is 
unwise  to  permit  more  than  five  or  six  deep  respiratory  excursions  of 
this  nature  at  one  time,  although  in  suitable  cases  they  may  be  repeated 
several  times  during  the  day.  Many  instructors  in  physical  exercise 
insist  upon  the  backward  movement  of  the  arms  until  the  dorsal  surfaces 
of  the  hands  touch  each  other  in  the  back  during  inspiration,  the  arms 
being  brought  forward  in  expiration.  At  the  time  of  inspiration, 
with  or  without  supplemental  arm  movements,  the  body  may  be  raised 
slightly  upon  the  toes  and  held  in  that  position  as  long  as  the  breath 
is  retained.  The  use  of  a  breathing-tube  is  of  no  practical  benefit, 
though  in  some  instances  possessing  a  slight  moral  effect. 

It  is  important  to  bear  in  mind  that  the  great  majority  of  pulmo- 
nary invalids  who  are  induced  to  seek  medical  counsel  present  sufficient 
evidence  of  active  destructive  lesions  to  contraindicate  the  employment 
of  pulmonary  gymnastics.  In  the  presence  of  less  active  tuberculous 
infection,  with  partial  pulmonary  incapacity  through  subacute  or  chronic 
pathologic  changes,  the  utility  of  such  measures  cannot  be  denied.  Under 
these  conditions  it  has  been  my  custom  to  make  occasional  use  of  deep 
breathing  exercises  in  Colorado,  but,  owing  to  the  compulsory  increase 
of  respiratory  activity  at  high  altitudes,  the  practice  has  not  been  per- 
mitted unless  very  strong  indications  for  its  employment  are  presented. 


626  PKOPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

CHAPTER  XCII 
ENFORCEMENT  OF  AN  OPEN-AIR  EXISTENCE 

It  is  impossible  to  overestimate  the  importance  of  fresh  air  as  an  essen- 
tial factor  in  the  treatment  of  pulmonary  tuberculosis.  In  reality,  an  out- 
of-door  existence  is  an  indispensable  feature  of  modern  phthisiotherapy. 
Upon  this  all  medical  observers  are  of  a  single  mind,  but,  unfortunately, 
radical  differences  of  opinion  exist  as  to  what  constitutes  the  desirable 
qualities  of  inspired  air.  Puritj'  and  freshness  of  air,  attributes  unani- 
mously conceded  to  be  invaluable,  are  regarded  by  some  as  the  only  impor- 
tant considerations.  The  inhalation  of  an  atmosphere  cariying  a  proper 
amount  of  oxygen  and  devoid  of  injurious  contamination  is  asserted  by 
some  to  be  productive  of  the  fullest  possibilities  of  improvement.  Irre- 
spective of  other  qualities  of  atmosphere  and  of  the  environment,  fresh 
air,  in  its  influence  upon  the  course  of  tuberculosis,  is  proclaimed  by 
these  oljservers  to  be  the  same  wherever  found.  Regardless  of  such 
essential  features  of  climate  as  dryness,  temperature,  sunshine,  altitude, 
atmospheric  pressure,  and  wind  movement,  with  their  known  modify- 
ing effects  upon  the  respiration,  circulation,  digestion,  skin,  nervous 
system,  and  the  general  tone  of  the  organism,  the  contention  is  incon- 
ceivably made  that  the  sole  de.sideratum  is  the  inhalation  of  oxj^gen- 
ated  air.  Thus  it  has  been  announced  broadcast  that  quite  as  good 
results  may  be  obtained  in  one  place  as  in  another,  provided  the  air  is 
pure  and  fresh.  This  fallacious  doctrine  has  been  preached  with  a 
devotion  and  fanaticism  worth}'  of  a  truer  cau.se  by  many  who  should 
recognize  the  folly  of  subscribing  to  such  an  article  of  faith.  In  pur- 
suance of  this  delusion,  the  tUctum  has  gone  forth  that  fresh  air  suited 
to  the  neetls  of  the  consumptive  may  be  secured  in  the  large  cities 
as  well  as  in  the  country,  at  the  seashore  as  well  as  in  the  moun- 
tains, in  damp  marshy  regions  as  well  as  upon  dry  sandy  soil,  and 
in  a  district  characterized  by  fog,  cloud,  and  rain  as  well  as  in  the 
land  of  almost  perpetual  sunshine.  It  is  not  designed  at  this  time  to 
encroach  even  briefly  upon  the  merits  of  the  various  climatic  attributes 
in  the  treatment  of  consumption,  a  subject  reserved  for  future  dis- 
cussion, but  it  is  desirable  en  passant  to  tlenounce  emphatically  the 
false  notions  often  entertained  with  reference  to  the  role  of  fresh  air, 
exclusive  of  all  other  modifying  conditions  of  atmosphere  and  environ- 
ment. 

Even  should  it  be  assumed,  however,  that  fresh  air  is  but  fresh  air 
in  any  locality,  decided  issue  must  still  be  taken  with  the  teaching  that 
this  feature  constitutes  the  all  in  all  of  an  outdoor  existence.  It  matters 
greatly  whether  the  air  is  obtained  in  the  alleys  and  back  yards,  upon  the 
house-tops  and  fire-escapes,  and  in  densely  populated  chstricts  or  in 
properly  constructed  porches,  shacks,  or  tents  in  the  open  country. 
Further,  a  factor  of  no  little  importance  relates  to  the  manner  in  which, 
through  details  of  arrangement,  fresh  air  is  provided  for  the  pulmonary 
invalid.  The  practical  benefits  to  be  derived  from  exposure  to  outdoor 
air  are  enhanced  or  lessened  according  to  the  opportunities  afforded  for 
the  acquirement  of  an  environment  adapted  to  the  individual.  No 
principle  of  treatment  throughout  the  long  course  of  pulmonary  tuber- 
culosis is  established  more  conclusively,  than  the  necessity  of  rendering 


ENFORCEMENT    OF    AN    OPEN-AIR    EXISTENCE  627 

the  consumptive  comfortable  physically,  and  of  inspiring  a  cheerful  mental 
attitude  through  the  influence  of  pleasant,  properly  supervised  sur- 
roundings. 

It  is  essential  that  phthisical  patients  should  spend  not  merely 
a  brief  portion  of  the  day  out-of-doors,  but  should  remain  in  the 
open  air  as  many  hours  out  of  the  entire  twenty-four  as  weather  con- 
ditions will  permit.  It  is  far  from  sufficient  to  advise  the  invalid  to 
stay  out-of-doors  as  much  as  possible.  If  left  to  the  exercise  of  his  own 
judgment  and  inclinations,  the  period  of  fresh-air  existence  is  lamentably 
short,  and  usually  accompanied  by  unfortunate  indiscretions  in  the  way 
of  physical  exertion.  For  consumptives  to  obtain  fresh  air  at  all  hours, 
and  at  the  same  time  to  remain  completely  at  rest,  it  follows  that,  in 
addition  to  definite  instructions  of  such  a  nature,  special  provision  must 
be  made  for  this  purpose. 

The  i-equirements  to  be  observed  relate — (1)  to  devices  for  securing  the 
maximum  amount  of  fresh  air  with  the  invalid  at  rest  within  doors ;  and 
(2)  to  arrangements  for  the  comfort  and  shelter  of  the  patient  if  in  the 
open  air.  No  matter  how  spacious  the  indoor  ajiartments,  how  perfect 
the  ventilation,  how  flooded  with  sunshine,  nor  how  equipped  for  pro- 
tection from  drafts,  there  can  exist  no  compensation  for  lack  of  outdoor 
accommodations.  In  case  facilities  for  open-air  existence  are  entirely 
unavailable,  and  partiriilaily  wliru  circumstances  do  not  permit  the 
occupancy  of  lar^c  miuhx  ,  \\cll-\i'iiiil:ited  rooms,  several  ingenious 
methods  have  licni  prc-i'iiicd  in  pci'imi  the  inhalation  of  pure  air.  An 
arrang(Miicin  kimwuas  the  aorarium  provides  for  the  partial  outward 
extension  nl'  a  cut  l)ed  from  an  open  window,  the  head  and  shoulders 
of  the  pa.liciit  thus  being  in  the  open  air,  though  protected  by  an 
awning  outwide  the  window.  The  sleeping-room  in  which  reposes 
the  body  of  the  patient  is  kept  measurably  warm  in  cold  weather 
by  the  interposition  of  a  heavy  curtain  suspended  from  the  lower 
portion  of  the  raised  lower  window-sash  and  tucked  around  the  body 
of  the  patient.  The  sides  may  be  opened  or  closed  at  will,  ventila- 
tion being  secured  through  the  lower  and  upper  part  of  the  aerarium, 
the  roof  of  which  is  double  and  provided  with  an  ojiening.  Another 
contrivance  of  more  doubtful  utility  is  the  conduction  of  air  from  the 
outside  to  the  head  of  the  patient  in  the  sleeping  room  through  a  large 
flexible  tube  consisting  of  heavy  cloth  supported  by  a  series  of  light  but 
stiff  rings.  This  arrangement,  for  obvious  reasons,  appears  less  practic- 
able than  resourceful. 

The  window-tent  devised  by  Dr.  S.  A.  Knopf  embodies  all  the  desir- 
able features  of  the  aerarium  and  obviates  some  of  the  disadvantages. 
The  window-tent  is  virtually  an  inside  awning,  consisting  of  canvas 
stretched  upon  an  iron  frame  attached  to  the  lower  half  of  the  window, 
as  shown  in  Fig.  131.  The  tent  is  designed  to  rest  upon  a  single  bed, 
and  to  inclose  the  upper  portion  of  the  patient's  body,  its  height, 
length,  and  degree  of  curvature  being  necessarily  dependent  upon  the 
dimensions  of  the  window.  In  its  construction  the  effort  is  made  to 
provide  fresh  outdoor  air  which  shall  not  be  allowed  to  mix  with  the 
air  in  the  room.  In  case  there  is  but  a  single  window,  a  measure  of  venti- 
lation for  the  room  is  afforded  by  an  air-space  of  about  three  inches 
between  the  top  of  the  window-tent  and  the  lower  edge  of  the  sash. 
This  space  may  be  reduced  or  closed  entirely  by  lowering  the  window. 
It  would  appear  that  the  access  of  fresh  air  rendered  possible  by  this 


bii»  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

method  is  much  greater  than  nhtains  in  Idwcr  berths  of  Pullman  sleeping- 
cars,  though  the  conditions  arc  iu  -nini'  n-|MMts  quite  similar.  With  the 
upper  berth  made  up  and  the  curtains  iii;litly  ilrawn  the  traveler  in 
the  lower  compartment  occupies  throughout  his  entire  length  a  modified 
wdndow-tent.  The  comparatively  small  window  opening  is  practically 
offset  by  the  forcible  entrance  of  air  incident  to  the  rapid  motion  of  the 
car,  j^et  the  air  within  this  confmed  space,  even  during  hot  weather,  when 
the  windows  are  open,  often  becomes  noticeably  foul.  It  is  apparent  that 
a  vitally  important  feature  of  the  wimlow-tent  is  the  opportunity  afforded 
for  the  egress  of  expired  air  by  virtue  of  the  proportionately  large  open- 
ing. An  added  factor  is  the  small  capacity  of  the  inclosed  tent,  with  its 
rounded  upper  surface  facilitating  the  course  of  the  air-current.  In 
describing  the  ventilation  of  the  window-tent  Knopf  states  that  the 
cold  air  enters  at  the  bottom  of  the  open  space,  descrilies  a  quarter 
circle,  and  makes  its  exit  at  the  top,  carrying  with  it  the  exhaled  carbon 


Fig.  131.— Dr.  S.  A.  Knopfs  window-tent. 

dioxid.  This  I  have  verified  by  the  use  of  a  delicate  instrument  known 
as  the  air  meter,  the  current  being  perceptibly  inward  at  the  bottom 
and  outward  at  the  top.  In  cold  weather  it  is  apparent  that  the  outward 
direction  of  the  air-current  at  the  top  is  facilitated  b}-  the  egress  of  heated 
air  from  the  room  through  the  aperture  above  the  window-tent.  This, 
of  course,  would  not  obtain  during  warm  weather  or  when  the  window 
is  brought  down  to  the  level  of  the  canvas.  It  is  also  found  that  the 
degree  of  ventilation  within  the  tent  varies  materially  according  to  the 
chrection  of  the  wind  and  the  temperature  of  the  surrounding  atmo- 
sphere: in  other  words,  it  is  dependent  somewhat  upon  the  temperature 
relation  of  the  inspired  and  expired  air.  The  cour.se  and  vigor  of  the 
air-current  within  the  tent  are  greater  in  proportion  as  the  temperature 
of  the  exhaled  portion  is  ivanner  than  that  of  the  outside  atmosphere. 
In  cold  weather  the  warm  expired  air  rises  to  the  upper  portion  of  the 
tent  and  makes  its  exit  in  that  region,  its  place  being  taken  by  the 


ENFORCEMENT    OF    AN    OPEN-AIR    EXISTENCE  629 

entrance  of  cold  air  at  the  base.  This  is  not  true  to  an  equal  extent  in 
warm  weather,  at  which  season  an  additional  aid  to  the  air  movement 
seems  particularly  desirable.  In  the  summer-time  the  window-tent  is 
of  less  practical  value  than  in  winter,  as  opportunities  for  otherwise 
obtaining  fresh  air  are  usually  ample.  Moreover,  unless  a  north  window 
be  utilized,  the  tent  is  converted  into  a  veritable  oven,  the  heat  of  the 
sun  becoming  well-nigh  unbearable.  Under  such  circumstances  an 
outside  awning,  to  afford  protection  from  the  summer  heat,  appears 
desirable.  At  any  season  of  the  year  ventilation  of  the  tent  may  be 
facilitated  by  the  use  of  a  small  inexpensive  fan  propelled  by  air,  and 
possibly  by  the  insertion  into  the  upper  third  of  the  window-frame  of  a 
piece  of  wood  about  one  foot  wide,  slanting  downward.  A  substitute  for 
the  window-tent  has  been  devised  by  Dr.  Charles  Denison.  This  is 
known  as  the  sleeping  canopy  and,  like  the  preceding,  is  designed  to  pro- 
vide fresh  air  to  the  consumptive  who  may  be  confined  to  the  room. 
The  canopy  curtains  are  so  arranged  that  they  may  descend  from  the 
upper  portion  of  the  window  and  encircle  the  exposed  sides  of  the  bed. 
At  best,  it  is  hard  to  conceive  how  the  aerarium,  window-tent,  or  other 
device  for  putting  the  patient  at  an  open  window  can  be  productive  of 
the  very  best  results.  While  such  ingenious  arrangements  are  assuredly 
better  than  nothing,  their  disadvantages  consist  of  the  limited  amount 
of  fresh  air  capable  of  attainment,  the  obstacles  in  the  wiiy  of  special 
care  and  nursing  on  account  of  the  hood  arrangement ,  and  the  psychic 
influence,  which  hardly  can  be  regarded  as  encouraging  or  inspiring. 

Arrangements  for  the  comfort  and  shelter  of  patients  privileged  to 
enjoy  an  outdoor  existence  are  scarcely  less  important  than  the  inhala- 
tion of  pure  fresh  air.  An  essential  feature  in  the  acquirement  of  physi- 
cal comfort  for  the  outdoor  consumptive  relates  to  the  adequate  protec- 
tion of  the  body  despite  low  degrees  of  temperature.  Coolness  of  air 
presents,  as  a  general  rule,  no  insuperable  objection  to  the  policy  of  stay- 
ing out-of-doors  at  all  hours.  In  fact,  it  has  been  my  observation  that 
more  satisfactory  results  are  often  obtained  during  cold  weather  than 
during  the  summer  months,  unless  patients  are  permitted  to  inspire  the 
bracing  air  of  the  mountains  at  this  time  and  experience  the  exhilarating 
effects  of  a  new  environment.  Even  when  exposed  to  extremely  low 
temperature,  provided  proper  attention  be  given  to  the  maintenance  of 
body  heat,  patients  are  found  to  do  extremely  well  in  the  open  air,  on 
account  of  the  stimulation  of  the  normal  functions  by  the  cold.  It  is,  of 
course,  important  to  avoid  chilling  of  the  surface  of  the  body,  but  this 
may  be  prevented  through  the  use  of  suitable  clothing  and,  when  neces- 
sary, by  the  application  of  hot-water  bottles  to  the  feet  or  about  the  body. 
It  is  desirable  during  the  winter  months  that  the  patient  should  be  kept 
moderately  warm  under  all  circumstances,  but  this  does  not  imply  the 
necessity  of  bundling  up  in  heavy  wraps,  chamois-skin  undergarments, 
and  chest  protectors  to  such  an  extent  as  to  interfere  with  the  proper 
function  of  the  skin.  The  important  desideratum  is  that  the  invalid  be 
made  comfortable  through  the  use  of  proper  apparel.  Much  harm  may 
result  from  the  wearing  of  clothing  ill  adapted  to  the  state  of  the  weather, 
frequent  colds  and  physical  debility  ensuing  from  the  burden,  perspira- 
tion, and  subsequent  chilling  occasioned  by  too  heavy  apparel.  Patients 
should  be  taught  that  the  actual  utility  of  their  undergarments  is  more 
dependent  upon  the  fabric  and  construction  than  upon  the  weight.   , 

In  extremely  cold  weather  moderately  heavy  woolen  underclothing  is 


630  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

almost  indispensable.  In  rigorous  climates  a  double  suit  or  a  woolen 
chest  protector,  with  an  extra  pair  of  socks,  is  sometimes  necessary. 
The  wearing  of  chamois-skin  garments  or  of  newspapers  attached  to  the 
underclothing  should  be  intertlicted,  on  account  of  their  imperviousness 
to  air  and  the  tendency  to  produce  relaxation  of  the  skin.  Cotton  gar- 
ments or  those  made  of  outing  flannel  should  not  be  worn  next  the  skin 
in  any  season  or  in  any  locality.  The  cotton  being  a  good  conductor  of 
heat,  serves  to  promote  radiation  of  animal  heat  from  the  body  in  cold 
weather,  and  to  convey  the  overheated  air  directly  to  the  body  in  sum- 
mer. Its  activity  as  a  heat  conductor  is  intensified  bj'  the  retained 
moisture  resulting  from  perspiration.  In  the  milder  climates  and  during 
less  severe  weather  in  cold  regions,  a  light,  loosely  fitting  woolen  garment 
is  preferable  to  the  heavy  skin-tight  flannels  so  frequently  worn.  In  very 
many  instances  the  maximum  of  comfort  may  be  obtained  by  the  use  of 
linen-mesh  garments,  which  are  light  in  weight,  non-irritating,  non- 
shrinking,  and  productive  of  no  interference  with  the  proper  function 
of  the  skin. 

In  the  matter  of  dress  for  the  feet  an  important  consideration  relates 
to  the  avoidance  of  sweating.  Socks  should  be  of  wool,  but  not  too 
heavy,  as  perspiration  is  induced,  especially  by  the  use  of  old-fashioned 
knit  stockings.  When  this  takes  place,  an  immediate  change  of  socks, 
with  vigorous  rubbing  of  the  feet,  is  desirable.  The  practice  of  inclosing 
the  feet  and  ankles  in  heavy  overshoes  is  less  commendable  than  the 
use  of  stout,  thick-soled  .shoes  or  felt  boots.  In  extreme  weather  the 
feet  may  be  kept  warm  by  the  use  of  a  hot-water  bottle  and  blanket. 

The  wearing  of  sweaters  with  a  heavy  roll  tightly  incircling  the  neck 
is  more  or  less  objectionable,  as  local  perspiration  is  induced  and  the 
susceptibility  to  colds  and  sore  throats  increased.  The  same  disad- 
vantage obtains  from  inclosing  the  neck  Ijy  a  fur  collar,  save  in  the  coldest 
weather.  For  the  warmth  of  the  ears  it  is  much  better  to  i-esort  to  the 
use  of  the  time-honored  ear-muffs  than  to  employ  scarfs  or  fur  collars, 
unless  tlemanded  for  the  protection  of  the  face. 

At  night,  during  the  severity  of  the  winter,  the  patient  should  sleep 
upon  a  double  mattress,  or  a  pair  of  woolen  blankets  should  be  placed 
next  the  spring,  with  another  pair  of  blankets  resting  upon  the  mattress, 
in  order  to  prevent  the  penetration  of  cold  air  from  below  the  bed.  In 
many  instances  a  light  woolen  robe  may  l)e  placed  between  the  sheets, 
which  the  invalid,  if  desired,  maj^  wrap  around  the  body.  Consumptives 
often  prefer  to  .sleep  in  blankets  with  the  body  inclosed  in  woolen  pajamas. 
In  extreme  wi-athcr  slcc]iiii'i-lia!;s  may  be  utilized,  consisting  of  heavy 
woolen  mati'iial,  (HiiciiMK-  lined  with  fur  or  feathers,  and  buttoning 
closely  around  tin-  neck  and  boulders.  It  is  important  that  the  outer 
bed-clothing  should  not  be  too  heavj',  lest  sleep  may  be  disturbed  to  a 
considerable  extent.  Warmth  is  attained  far  more  from  the  quality  of 
the  material  used  for  bed-covering  than  from  the  weight.  Old-fashioned 
quilts  and  comforters  should  be  dispensed  with  whenever  possible,  and 
woolen  blankets  substituted  in  their  place,  while  for  the  well-to-do 
eiderdown  quilts  are  advantageous  on  account  of  their  lightness.  It  is 
often  deisirable  to  protect  the  head  with  a  light  woolen  night-cap,  which 
may  be  drawn  over  the  ears,  leaving  the  face  exposed.  Protection  is 
thus  afforded  to  all  portions  of  the  liody  likely  to  suffer  from  exposure 
except  the  no.se.  Occasionally  patients  complain  bitterly  of  the  sen- 
sation of  cokl  experienced  at  night  at  the  very  end  of  the  nose.     To 


ENFORCEMENT    OF    AN    OPEN-AIR    EXISTENCE  631 


obviate  this  difficulty  I  have  sometimes  made  use  of  a  device  sug 
by  Dr.  James  A.  Hart,  formerly  of  Colorado  Springs,  consisting  of  a  piece 
of  thick  flannel  or  felt  which  is  placed  upon  the  nose  and  securely 
fastened  by  strips  of  rubber  adhesive  plaster  extending  horizontally 
upon  the  cheeks. 

In  addition  to  the  protection  of  the  bodfj  by  means  of  proper  cloth- 
ing, it  is  important  that  various  means  of  outside  shelter  be  devised. 
During  the  summer  provision  should  be  made  in  all  cases  for  protection 
from  the  intense  heat  of  the  sun  and  the  sudden  showers,  and  also  means 
afforded  for  the  avoidance  of  nervous  irritation  and  loss  of  sleep  pro- 
duced by  the  ubiquitous  fly  or  mosquito.  In  winter  adequate  shelter 
must  be  provided  from  the  chilling  blasts  and  protracted  storm,  indicat- 
ing in  no  uncertain  manner  the  violence  of  the  elements  at  this  time  of 
year. 

A  superimposed  roof  of  some  kind  is  the  first  essential  in  the  way  of 
shelter  for  the  tuberculous  invalid  in  the  open  air.  It  is  true  that  in 
Colorado,  New  Mexico,  Arizona,  and  other  comparatively  arid  regions 
the  consumptive  is  often  permitted  to  sleep  in  perfect  safet}"  under  no 
other  canopy  than  the  starry  skies,  but  a  similar  attempt  in  less  favored 
regions,  even  in  pleasant  weather,  is  not  to  be  regarded  as  an  ideal  con- 
servative practice. 

Next  to  the  roof,  the  most  desirable  feature  of  an  outdoor  abode 
for  the  invalid  is  the  presence  of  at  least  two  protecting  contiguous 
walls.  These  are  requiretl  to  give  proper  shelter  in  the  event  of  storm 
or  wind,  at  which  times  the  bed  may  be  moved  into  the  sheltered  corner, 
beyond  the  reach  of  snow  and  rain.  A  third  wall  is  by  no  means  indis- 
pensable, though  sometimes  of  signal  advantage  in  inclement  weather. 
Opportunity  to  inclose  temporarily  the  air-space  upon  the  third  side, 
and  to  remove  subsequently  the  awning  or  screen  at  will  is,  therefore, 
a  feature  of  added  value.  In  order  to  afford  satisfactory  ventilation,  it 
is  absolutely  necessary  that  the  front  or  remaining  side  be  kept  entirely 
open. 

Under  all  circumstances  the  floor  should  be  of  matched  wood, 
entirely  impervious  to  air,  and  raised  a  considerable  distance  from  the 
ground.  The  front  exposure  should  be  toward  the  sun  during  a  portion 
of  the  day,  but  it  is  not  at  all  essential  that  it  face  the  south.  Means 
for  ready  communication  with  a  nurse  or  attendant  in  case  of  need  is  a 
prime  necessity. 

Of  further  advantage  is  proximity  to  a  commodious,  well-heated 
apartment,  into  which  the  bed  may  be  moved  at  any  time.  This 
not  only  permits  the  removal  of  the  patient  into  the  house  during 
unpleasant  weather,  but  also  secures  the  privacy  of  the  sleeping-room 
for  bathing  purposes,  as  well  as  gi-eatly  facilitating  toilet  arrangements. 
Another  advantage  of  no  little  value  consists  of  the  easy  accessibility 
of  the  kitchen,  refrigerator,  ami  pantry,  enabling  the  invalid  to  receive 
food  in  appetizing  form.  Lighting  arrangements  are  also  greatly  simpli- 
fied by  an  immediate  contiguity  of  the  dwelling  and  the  easy  extension 
of  electric  wiring.  Freedom  from  intrusion  and  protection  from  the 
stare  of  passers-by  represent  important  desiderata  to  be  secured  by  de- 
tails of  location  and  construction.  Protection  from  the  glare  of  the  sun 
by  means  of  easily  adjusted  screens,  and  from  the  annoyance  of  insects 
through  the  generous  use  of  wire  netting,  is  an  added  feature  of  comfort 
and  utility. 


632  PROPHYLAXIS,    GENERAL    AND    SPECIFIC   TREATMENT 

From  the  foregoing  considerations  it  is  at  once  apparent  that  all 
the  detailed  advantageous  conditions  can  be  supplied  only  by  special 
provision  for  porch  accommodations.  The  second-story  veranda  as 
above  described  is  undoubtedly  the  ideal  arrangement  for  an  open-air 
existence  of  the  pulmonary  invalid,  but,  unfortunately,  this  plan  is  not 
within  the  reach  of  all  sufferers  from  consumption.  Numerous  methods 
have  been  devised  looking  toward  the  acquirement  of  fresh  air  at  a  modi- 
cum of  expense.  Several  of  these  contrivances  have  been  capable  of 
application  at  certain  seasons  of  the  year,  but  have  failed  dismally  at 
other  times.  Some  have  succeeded,  to  be  sure,  in  offering  to  the  con- 
sumptive a  sufficient  amount  of  fresh  air,  but  at  the  expense  of  a  large 
measure  of  his  physical  comfort  and  peace  of  mind.  At  other  times 
the  invalid,  if  rendered  comparatively  comfortable,  is  necessarily 
deprived,  to  some  extent,  of  the  very  air  which  is  so  strenuously  sought. 

Tent  life,  ardently  advocated  by  some  observers,  is  open  to  many 
unavoidable  objections.  It  is  manifestly  difficult  or  impossible  by 
the  use  of  tents  to  supply  the  required  conditions  already  described 
as  constituting  an  ideal  arrangement.  The  tent  occupant  is  neces- 
sarily near  the  ground  for  a  prolonged  period,  and  save  in  favorable 
climates,  is  exposed  to  a  considerable  degree  of  dampness,  which  is 
enormously  increased  in  wet  weather.  In  addition  to  the  inevitable 
inconvenience  and  deprivation,  there  is  much  difficulty  in  cooler  weather 
in  securing  physical  comfort  combined  with  proper  ventilation.  No 
matter  how  modern  the  effort  toward  sufficient  ventilation,  tents  are 
usually  cold  in  winter,  if  not  overheated  at  the  expense  of  fresh  air, 
and  often  extremely  oppressive  in  summer  unless  open  to  direct  drafts. 
It  thus  happens  that  recourse  to  tent  life,  without  special  supervision 
as  to  details  of  construction  and  mode  of  habitation,  is  attended  by 
results  woefully  disastrous  to  the  unsuspecting  invalid,  deluded  with 
the  belief  that  "roughing  it"  is  a  panacea  for  tuberculosis.  Rain- 
proof canvas  is,  of  course,  air-proof  as  well,  and  while  of  little  value  in 
excluding  the  cold,  serves  effectually  to  keep  out  fresh  air.  In  cold 
or  boisterous  weather  the  occupant  is  of  necessity  compelled  to  remain 
in  a  small,  improperly  heated,  and  poorly  ventilated  air-space,  harassed 
meanwhile  by  the  continual  flapping  of  the  canvas  and  the  spasmodic 
tugging  of  the  guy  ropes. 

Numerous  attempts  have  been  made  to  remedy  the  glaring  defects 
common  to  the  ordinary  tent  of  former  j^ears.  Important  improve- 
ments have  been  embodied  in  the  Gardiner,  Tucker,  and  Fisher  tents, 
the  two  former  being  employed  somewhat  extensively.  The  Gardiner 
tent,  devised  by  Dr.  C.  F.  Gardiner,  of  Colorado  Springs,  consists  of  a 
hexagonal  wooden  frame  without  center  pole,  but  with  vertical  sides  and 
conic  top.  The  canvas  is  stretched  over  the  framework  and  fastened 
to  a  I'aised  board  floor,  thus  dispensing  with  the  necessity  of  stakes  or 
guy  ropes.  Air  is  allowed  to  enter  at  the  bottom  and  around  the  lower 
edges,  exit  being  provided  at  the  conic  top,  through  which  a  stovepipe 
may  emerge  if  desired.  The  sides  may  be  turned  back  or  kept  tightly 
laced,  according  to  weather  conditions.  The  Tucker  and  Fisher  tents 
also  afford  excellent  ventilation  facilities,  but  the  expense  in  each 
instance  is  considerable  and.  upon  the  whole,  the  results  attained  less 
satisfactory  than  can  be  secured  from  the  erection  of  other  varieties  of 
sleeping  structures  at  a  diminished  cost. 

While  it  has  been  my  practice,  as  a  general  rule,  to  oppose  the  occu- 


ENFORCEMENT   OF    AN    OPEN-AIR    EXISTENCE 


633 


pancy  of  tents  by  my  patients,  fairly  gratifying  results  in  recent  sum- 
mers iiave  attended  tlae  use  of  tents  in  the  mountains  by  small  colonies 
of  invalids  in  straightened  circumstances.  The  form  of  tent  usually 
employed,  for  which  no  originality  is  claimed,  but  Vhich  subserves  all 
practical  purposes  better  than  any  other  model  I  have  observed,  is 
shown  in  the  accompanying  illustration  (Fig.  132).  The  important 
features  consist  of  its  comparatively  slight  expense,  its  large  size,  the 
dimensions  being  12  by  14  with  a  height  of  10  feet,  the  tightly  matched 
wooden  floor  raised  considerably  from  the  ground,  the  vertical  wooden 
sides  to  a  distance  of  three  feet,  the  upper  portion  of  the  sides  consisting 
of  canvas  upon  adjustable  frames,  the  extension  of  the  top  well  beyond 
the  sides  of  the  tent,  thus  effectually  excluding  the  rain  without  the  air, 
the  use  of  the  double  top  or  fly  thus  minimizing  the  heat  to  a  percep- 
tible degree,  the  sliding  shade  insuring  privacy  at  night  without  obstruct- 
ing the  entrance  of  fresh  air,  and  finally  the  canopy  of  large  meshed 


Fig.  132. — Inexpensive  tent  adapted  for  tlie  use  of  pulmonary  invalids  during  the  summer  months, 


fly  netting  over  the  bed.  It  is  easy  to  understand  that  during  the 
summer  months  the  erection  of  fifteen  or  twenty  similarly  constructed 
tents  upon  high,  dry  and  sloping  ground  in  close  proximity  to  an  estab- 
lishment, containing  an  excellent  dining-room,  is  of  vast  benefit  to  a 
class  of  pulmonary  invalids.  Another  form  of  tent  appropriate  for  occu- 
pancy during  the  warm  weather  is  shown  in  Fig.  133. 

Various  forms  of  wooden  shelters  for  consumptives  have  been 
designed  from  time  to  time,  all  based  upon  the  same  principle  as  a 
somewhat  elevated  porch.  Among  the  desirable  features  embraced 
by  these  contrivances  are  cheapness  of  construction,  protection  from 
the  elements  by  an  overhanging  roof  and  an  inclosure  upon  three  sides, 
abundance  of  fresh  air,  and  in  some  instances  communication  with  an 
adjoining  inside  room  with  heating  and  toilet  facilities.  A  disadvantage 
of  an  enforced  recourse  to  such  improvised  accommodations  relates 
to  the  depressing  effect  upon  the  patients  from  the  crudeness  of  con- 


634  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

struction,  and  the  frequent  uninviting  environment.     Other  drawbacks 
to  their  practical  efficacy  for  advanced  cases  consist  ot  inaccessibility 


1  housekeeping  purposes. 


to  the  dwelling,  remoteness  ot   the  kitchen,  and  consequent  difficulty 
in  serving  properly  prepared  food,  the  frequent  absence  of  nurse  or 


ENFORCEMENT    OF    AN    OPEN-AIR    EXISTENCE 


635 


attendant,  especially  at  night,  and  a  location,  as  a  rule,  too  near  the 
ground,  which  becomes  wet  and  damp  in  unfavorable  weather.  How- 
ever, these  wooden  structures,  notably  Millet's  sleeping  shack  and  King's 


lean-to,  are  eminently  useful  devices,  far  superior  to  any  form  of  tent 
in  cold  weather,  and  appropriate  for  a  large  number  of  patients.     The 


c  appropriate  for  warm  weather. 


sleeping  shack  is,  in  effect,  a  porch  severed  from  all  communication 
with  the  house,  thus  entailing  certain  disadvantages,  as  described. 

It  is  my  custom  to  obviate  these  objections  during  the  summer 
months  by  providing  in  the  mountains,  for  a  class  of  patients,  shacks 


636 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


that  are  suitable  not  only  for  sleeping,  but  for  hons,  k< ,  pliifi  purposes. 
These  are  inexpensive,  but  perfectly  comfortabli"  uml  well  adapted  to 
small  families.  A  view  of  these  somewhat  priniiti\e  Imt  none  the  less 
inviting  abodes  secured  at  a  minimum  of  expense  is  shown  in  the 
accompanying  photographs. 

The  lean-to  arrangement,  as  developed  by  Dr.  King,  of  Loomis  Sana- 
torium, is  virtually  a  sleeping  shack  designed  for  the  accommodation  of 
from  eight  to  sixteen  people.  A  wide  shed  is  erected  with  a  projecting 
roof  over  an  open  front.  The  ends  may  be  open  or  closed,  according  to 
the  requirements  imposed  by  weather  conditions.  The  beds,  which  are 
placed  in  a  row  in  the  rear  of  the  inclosure,  facing  the  opening  in  front, 
are  assured  of  sufficient  protection  from  beating  rain  or  snow.  Space  is 
afforded  for  reclining  chairs  between  the  foot  of  the  bed  and  the  front 
of   the   inclosure.     Canvas   curtains   are   suspended   along   the   open 


exposure,  which  is  thus  capable  of  being  closed  at  certain  times.  The 
most  recent  modification  of  the  original  lean-to  consists  of  the  con- 
struction of  a  well-equipped  dressing-,  bath-,  and  toilet-room,  and  a 
spacious  sitting-room  connecting  two  separate  apartments  for  sleeping 
purposes. 

An  ingenious,  somewhat  expensive,  and  rather  impracticable  device 
is  the  revolving  shelter,  so  constructed  that  the  support  of  the  building 
is  borne  by  wheels  which  traverse  a  circular  iron  rail  aroimd  the  base, 
with  a  pivot  at  the  center.  The  only  important  principle  invoked 
by  the  substitution  of  these  structures  for  the  ordinary  sleeping  shack, 
is  the  means  afforded  for  avoiding  more  completely  the  chilling  effect 
of  wind  and  storm,  as  well  as  for  securing,  if  desired,  the  greatest  possible 


ENFORCEMENT    OF    AN    OPEN-AIR    EXISTENCE 


637 


amount  of  sunshine.  The  revolving  shelter  may  be  of  any  size,  of 
either  cheap  or  substantial  construction,  of  nearly  square  or  circular 
form,  and  equipped  with  sliding  windows  or  adjustable  sides.  After 
some  opportunities  for  observation  relative  to  the  utility  of  such  a 
contrivance  erected  six  or  seven  years  ago,  at  a  cost  of  $500,  in  con- 
nection with  the  Oakes  Home  in  Denver,  evitlence  has  been  lacking 
to  justify  its  employment  in  favorable  climates. 

Upon  the  whole,  it  appears  that,  if  more  or  less  unfavorable  accom- 
modations are  good  for  a  class  of  people  unable  to  secure  anything 
else-,  a  commodious,  specially  arranged  porch  opening  directly  from 
the  sleeping-room  upon  the  second  floor  is  infinitely  better  for  others. 


So  high  a  value  is  placed  upon  this  arrangement  that  I  frequently 
insist  upon  the  construction  of  such  porches  even  by  patients  who 
take  houses  under  lease.  The  porches  should  be  covered  by  a  perma- 
nent roof,  sheathed  from  the  bottom  a  distance  of  three  feet,  with  a 
wide  sill,  and  inclosed  with  wire  screening,  as  shown  in  the  accom- 
panying illustration  (Fig.   137). 

It  has  been  advised  by  some  that  patients  should  remain  directly 
exposed  to  the  rays  of  the  sun  as  many  hours  as  possible,  regardless 
of  the  season.  To  this  principle  I  am  opposed,  as  it  may  happen  that 
a  porch,  comfortable  in  the  morning,  becomes  almost  unbearable  in 
the  afternoon,  and  vice  versa.     My  rule  is  to  permit  the  patient  to 


638 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


remain  in  the  direct  rays  of  the  sun  only  during  such  times  as  actual 
benefit  is  experienced,  and  to  remove  the  invalid  whenever  chscomfort 
supervenes.  It  is  not  altogether  the  varying  degrees  of  heat  from  the 
sun's  rays  that  produce  beneficial  results.  At  different  times  there  is 
demanded  a  judicious  exposure  to  direct  sunshine  or  protection  from 
the  intense  heat  according  to  the  state  of  the  patient  and  conditions 
of  weather. 

I  am  not  in  sympathy  with  an  application  of  the  theory  of  outdoor 
sleeping  at  night  regardless  of  other  considerations.  This  practice, 
when   advised   with   proper   discrimination,  is   capable  of   producing 


^^">^. 


inestimable  benefit  in  the  way  of  an  iniproxed  appetite  and  (.ligestion, 
with  an  increased  feeling  of  bien  lire,  but  its  routine  adoption  is  followed 
in  some  instances  by  harmful  results.  It  must  not  be  forgotten  that 
the  patient  at  all  times  must  be  kept  perfectly  comfortable,  as  well  as 
being  supplied  with  fresh  air.  In  extremes  of  weather  comfort  can  be 
secured  only  by  lowering  the  canvas  curtains,  and  closing  all  outside 
apertures  to  such  an  extent  as  to  preclude  proper  ventilation.  During 
severe  cold,  patients  not  only  are  more  comfortable  in  a  bed-room  with 
moderate  heating  facilities,  but  at  the  same  time  are  afforded  much 
better  ventilation  from  one  or  two  open  windows,  than  is  possible  upon 
an  outside  porch  \\  ith  all  curtains  tightly  closed.    Further,  it  has  been  my 


REGULATION    OF    DII 


639 


experience,  save  during  the  summer,  tliat  some  patients  do  poorlj^  wlien 
sleeping  out-of-doors.  An  explanation  is  found  in  the  varying  degree 
of  bronchial  irritation  coexisting  with  the  tuberculous  infection.  In 
so  far  as  the  bronchial  element  predominates,  by  just  so  far  is  the  cough 
made  more  distressing  and  the  general  condition  thereby  less  favorable 
through  exposure  to  the  cold  air  at  night.  During  the  winter  months 
the  thei-;ii>cutic  indication  for  cases  of  chronic  bronchitis  per  se  is  not 
fresh  air,  Imi  latlier  protection  from  drafts  and  exposure.     It  appears 


The  upper  sleeping  porcht 


consistent  and  wise  to  offer  bronchitic  patients  suffering  trom  com- 
plicating tuberculous  processes,  the  same  judicious  consideration. 
While  in  many  cases  there  is  no  direct  relation  between  the  extent  of 
the  tuberculous  change  and  the  amount  of  bronchial  irritation,  the 
fact  remains  that  severe  bronchial  disturbance  reacts  decidedly  to 
the  disadvantage  of  the  invalid.  This  is  especially  exhibited  in  the 
fatigue  incident  to  the  cough,  and  in  the  I'eflex  vomiting  after  the 
ingestion  of  food,  which  materially  interferes  with  nutrition. 


CHAPTER  XCIII 
REGULATION  OF  DIET 

The  vast  importance  attaching  to  the  diet  of  tuberculous  invalids 
is  demonstrated  by  the  fact  that  nutrition  is,  to  a  very  great  extent, 
the  measure  of  nature's  constructive  efforts  toward  an  arrest  of  the 
disease.     It  is  true  that  occasionally  individuals  develop  tuberculosis 


640  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

even  when  there  is  little  if  any  loss  of  weight,  and  that  others  exhibit 
improvement  despite  a  considerably  impaired  nutrition.  For  practical 
purposes,  however,  it  ma}'  be  assumed  that  improvement  in  the  general 
condition  and  in  the  state  of  the  tuberculous  process  is  fairly  commen- 
surate with  the  gain  in  nuti'ition.  Thus  an  increased  weight  within 
certain  limits  is  to  be  regarded  as  a  safe  criterion  of  the  tendency  of 
the  invalid  toward  restoration  to  health. 

The  first  great  proposition,  therefore,  is  to  so  improve  digestion 
and  assimilation  as  to  permit  a  substantial  increase  of  nutrition.  Rad- 
ical chfferences  of  opinion  exist,  however,  among  phthisiotherapeutists 
as  to  the  degree  to  which  efforts  should  be  made  toward  the  promotion 
of  body  weight.  It  is,  of  course,  apparent  that  the  greatest  success  will 
result  in  individual  instances  from  the  attainment  of  such  a  standard 
of  nutrition  as  corresponds  most  closely  with  health,  and  produces 
the  greatest  powers  of  resistance.  It  sometimes  happens  that  the 
tone  of  the  general  health  is  not  improved  by  excessive  gain  in  weight, 
with  the  attendant  disturbance  of  digestive  capacity  and  cardiac 
function.  The  increased  nutrition  may  be  associated  with  impairment 
of  metabolism  and  the  development  of  functional  changes  characteristic 
of  pathologic  obesity.  It  is  under  such  circumstances  that  tuberculous 
infection  secures  a  foothold  among  the  very  corpulent.  It  is  often 
impossible  to  state  with  accuracy  just  when  a  sufficient  improvement  of 
nutrition  has  taken  place,  as  the  progress  of  arrest  ma,y  become  retarded 
as  a  result  of  indiscriminate  "stuffing."  While  due  caution  should 
be  exercised  to  avoid  a  predominating  aim  toward  the  accumulation 
of  a  disproportionate  amount  of  fat,  the  comparative  possibilities  of 
producing  such  pathologic  condition  are  few,  and  the  dangers,  save  in 
exceptional  instances,  considerably  exaggerated.  Provision,  therefore, 
for  a  generous  and  sustaining  dietary  becomes  not  only  sane  and  rational, 
but  indeed  absolutely  essential. 

No  matter  how  rigid  the  regime  in  other  respects,  nor  to  what  degree 
the  strength  of  the  invalid  is  conserved  by  judicious  rest,  nutrition  must 
remain  largely  dependent  upon  the  ingestion  of  food  sufficient  to  supply 
the  natural  demands,  and  aid  directly  in  the  reparative  process.  Much 
obscurity  still  continues  to  inshroud  the  proper  detailed  application  of 
important  principles  of  diet  for  the  tuberculous  invalid.  In  the  midst 
of  the  widely  differing  concUtions  so  frequently  worthy  of  special  con- 
sideration, even  in  early  cases,  and  the  ever-varving  complications  inci- 
dent to  advanced  stages,  definite  information  is  often  lacking  with  refer- 
ence to  the  precise  amount  and  character  of  food  best  adapted  to  the 
promotion  of  nutrition.  Many  conflicting  notions  have  long  been  enter- 
tained relative  to  this  vital  consideration.  It  was  not  many  years  ago 
that  consumptives  were  advised  to  imbibe  generous,  if  not  inordinate, 
quantities  of  whisky.  The  ingestion  of  an  almost  unlimited  amount 
of  food  has  been  urged  from  time  to  time.  By  some  the  frequent 
use  of  lean  meat  has  been  strongly  recommended  and  by  others 
enjoined  altogether.  Conflicting  ideas  have  been  entertained  as  to 
the  relative  \alue  of  the  variou:;  vegetable  products,  leguminous 
articles  being  held  in  much  repute  by  some  and  considered  of  slight 
utilitj',  if  not  objectionable,  by  others.  A  high  estimate  is  placed  by 
a  great  many  observers  upon  the  value  of  raw  eggs,  milk,  cream,  and 
beef-juice;  while  nuts,  vegetable  juices,  meat -powders,  extracts,  and 
similar  preparations  are  vaunted  by  a  few. 


REGULATION    OF    DIET  641 

Until  a  comparatively  recent  period,  emphatic  insistence  was  made 
upon  the  necessity  of  an  elaborate  system  of  superalimentation.  It 
followed  that  in  the  attempt  to  carry  out  the  prmciples  of  excessive 
feeding,  the  physician  frequently  failed  to  take  cognizance  of  import- 
ant modifying  conditions  inherent  to  individual  cases.  In  numerous 
instances  a  highly  injudicious  stuffing  process  was  inaugurated  by  physi- 
cians endowed  with  more  energy  and  enthusiasm  than  with  scientific 
instincts.  Notwithstanding  the  existence  of  fever,  digestive  disturb- 
ances, and  repugnance  at  the  thought  of  eating,  instructions  were  issued 
to  pulmonary  invalids  to  partake  daily  of  a  most  extraordinary  quantity 
of  food,  regardless  of  its  capability  as  a  producer  of  heat-units,  or  of  its 
adaptability  to  the  peculiar  needs  of  special  cases.  Too  frequently  the 
quantity  of  the  food,  its  selection  as  regards  the  nutritive  value,  and  its 
appropriateness  in  the  presence  of  functional  disorders  was  left  entirely 
to  the  tastes  and  inclinations  of  the  patient. 

As  opposed  to  the  previous  superficial  practice  of  extreme  engorge- 
ment, with  its  distinctly  deleterious  results,  there  is  exhibited  at  pres- 
ent a  tendency  toward  mathematic  precision  in  conformity  with  a  fixed 
standard  of  diet,  representing,  upon  the  whole,  a  somewhat  imprac- 
ticable refinement  of  therapy.  It  is  obvious  that,  through  careful  atten- 
tion to  detail,  the  amount  and  character  of  the  food  may  be  so  regulated 
that  general  dietary  principles  may  be  formulated,  which  are  susceptible 
of  modified  individual  application. 

It  is  clear,  from  a  physiologic  point  of  view,  that  the  value  of  any 
general  system  of  feeding  to  be  accepted  as  an  approximate  standard  of 
dietetics  for  pulmonary  invalids  must  be  dependent  upon  the  relative 
caloric  value  of  the  various  food-stuffs  ingested.  While  nutrition  varies 
directly  according  to  the  heat-producing  properties  of  the  assimilated  or 
metabolized  food,  it  must  be  borne  in  mind  that  the  relative  proportion  of 
ingested  fats,  proteids,  and  carbohydrates  per  kilo  of  body  weight  bears 
no  invariable  relation  to  the  nourishment  of  the  individual.  In  other 
words,  the  caloric  value  of  the  food  eaten  by  the  patient  is  not  always 
a,  criterion  of  the  caloric  energy  imparted,  through  the  processes  of 
digestion  and  assimilation.  In  view  of  the  numerous  functional  and 
organic  changes  common  to  pulmonary  invalids,  it  is  apparent  that 
the  dietarj^  consideration  of  vital  importance  is  not  the  definite  quantity 
of  the  food,  nor  the  relative  proportion  of  the  various  inurcdicnts, 
but  rather  the  completeness  of  its  subsequent  assimilatinu.  ami  the 
reduction  of  physiologic  strain.  Owing  to  the  consideiuldc  xaiiation 
of  individual  metabolism  among  consumptives  and  the  degree  of 
taxation  imposed  upon  the  powers  of  digestion  and  assimilation,  the 
impracticability  of  an  ideal  standardized  diet  is  appreciated.  A 
definitely  systematized  diet,  although  theoretically  ideal  according  to 
the  principles  of  physiology,  is  utterly  incapable  of  detailed  practical 
application. 

The  observations  of  Voit,  Chittenden,  Folen,  Atwater,  Goodbody, 
Bardswell,  Chapman,  and  others  have  been  of  decided  interest  and 
value.  It  has  been  estimated  by  Voit  that  from  30  to  35  calories  per  kilo 
of  body  weight  are  required  daily  to  maintain  good  health  in  a  normal 
adult  while  at  rest,  and  about  40  calories  if  more  or  less  active,  repre- 
senting in  general  120  grams  albumin,  50  grams  of  fat,  and  500  grams 
of  carbohydrates.  These  figures  are  more  or  less  in  accord  with  the 
statement  of  the  late  Sir  Michael  Foster,  to  the  effect  that  the  proportions 

41 


642  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

of  food-Stuffs  consumed  by  healthy  man  were  as  follows:  100  to  130 
grams  albumin,  40  to  80  grams  of  fats,  and  450  to  550  grams  carbo- 
hydrates. Chittenden,  however,  has  taken  issue  with  these  figures, 
niaintaining  that  the  amount  of  food  ordinarily  taken  by  a  grown  man 
in  good  health  is  materially  less.  The  conclusions  of  Goodbody, 
Bardswell,  and  Chapman  are  to  the  effect  that  a  diet  properly  adapted 
to  a  pulmonary  invalid  should  contain  120  grams  of  albumin,  140  grams 
of  fat,  and  300  grams  of  carbohydrates.  Burton  Fanning  has  placed 
himself  in  accord  with  the  above  conclusions  in  indorsing  the  expediency 
of  a  substantial  increase  of  fats  and  a  corresponding  diminution  of 
carbohydrates  for  phthisical  patients.  In  this  country  a  numl)er  of 
observers  have  insisted  upon  a  slight  increase  of  the  albumin,  with  a 
great  addition  to  the  fats  and  a  diminution  of  one-half  of  the  carbo- 
hydrates. It  is  generally  believed  that  the  equivalent  of  about  2200  or 
2.300  calories  for  a  healthy  man  at  rest,  or  of  about  2700  or  2800  calories' 
w-hen  at  work,  should  be  increased  approximately  to  3500  or  5000 
calories  for  the  pulmonary  invalid,  according  to  the  state  of  digestion 
and  the  demonstrable  effect  of  the  diet  upon  body  weight.  It  is  known, 
however,  that  satisfactory  results  are  sometimes  attained  among 
consumptives  upon  the  daily  ingestion  of  not  over  25  calories  per  kilo 
of  body  weight,  while  failure  to  increase  nutrition  may  result  from  the 
consumption  of  double  this  amount.  Remarkable  gains  in  weight  ma}^ 
occasionally  follow  the  ingestion  of  a  phenomenal  number  of  calories 
daily,  sometimes  approaching  even  100  per  kilo,  but  it  is  the  opinion 
of  Goodbody,  Bardswell,  and  Chapman  that  such  overfeeding,  rather 
than  increasing  the  powers  of  resistance,  exerts  a  highly  deleterious 
effect. 

The  conclusions  of  Chittenden  as  to  the  evil  consequences  result- 
ing from  an  excessive  consumption  of  alljumin  have  been  ascribed 
by  Fisher  to  obtain  similarh"  among  pulmonary  invalids.  The  latter 
observer  a.ssumes,  on  the  basis  of  "physiologic  economy,"  that  with 
proper  selection  of  food,  embodjdng  a  certain  proportion  of  fat  elements, 
3000  calories  a  day  is  ample  for  the  nourishment  of  the  average 
con.sumptive,  although  this  is  admitted  to  be  no  more  than  the  amount 
consumed  by  a  healthy  person. 

It  is  important  to  point  out  that  although  the  principle  of  physiologic 
economy  is  sound  for  normal  iiicli\'iilua.!s.  it  docs  imt  jnllou-.  l)y  any 'means, 
that  the  essential  considd-atio,/  aiiicmii  iiuliiiniia;\  iinaliils  consi.sts  of 
making  the  slightest  possihiv  ilruKimls  \\\Mm  tlic  di-c-^tixe  and  eliminative 
apparatus,  nor  of  giving  the  hast  amount  of  food  necessarn  to  maintain  body 
weight.  Under  such  circumstances  the  question  properly  resolves  itself 
into  a  choice  of  the  lesser  of  two  evils.  The  decision  must  be  made 
between  a  gratifying  increase  of  nutrition,  with  corresponding  enhancetnent 
of  resisting  power,  even  at  the  expense  of  a  temporary  tax  upon  physio- 
logic functions,  or  an  economy  of  functional  demands,  with  the  unnec- 
essary sacrifice  of  a  large  portion  of  the  means  of  defense  against  an  insidi- 
ous and  relentless  di.sease.  In  the  presence  of  a  wasting  affection,  the 
obligation  is  assuredly  imperative  to  promote  the  powers  of  resistance 
through  prompt  recourse  to  vigorous,  though  rational,  superalimentation. 
In  general  it  is  essential  that  the  patient  should  take  daily  all  that  it  is 
possible  to  administer  within  the  limits  of  digestion  and  assimilation. 
The  word  "administer"  is  used  advisedly.  It  is  not  what  the  patient 
desires  to  satisfy  the  cravings  of  hunger,  it  is  not  what  he  is  willing  to 


REGULATION    OF    DIET  643 

take  or  even  what  he  feels  pciMiiiallx-  he  is  able  to  eat,  but,  after  carejul 
inquiry  as  to  the  ditjc^tiri  injiacihi.  it  is  uU  that  the  physician  and  nurse 
are  able  to  persuade  liini  to  mnest  through  their  personal  influence  and 
direction. 

The  system  of  superalimentation  is  subject  to  great  variation,  accord- 
ing to  the  individual,  principles  appropriate  for  one  class  being  entirely 
inapplicable  to  another.  The  very  greatest  importance  attaches  to  the 
enjoyment  of  a  good  appetite  and  digestion.  Under  these  conditions 
it  is  quite  unnecessary,  for  practical  purposes,  to  institute  any  elaborate 
system  pertainiu,'.:  to  the  jtcljiistineiit  of  the  diet;i,r>-.  A  aciierous  mixed 
diet  in  .such  casrs,  without  special  fefei'elice  to  tjie  ivLitix'i-  Jiroportion 
of  proteids,  fal.^.  ami  raj'l.oh>-,lratr.s,  is  usually  all  sutlicieiit.  It  must 
not  be  assunieil.  !io\m'\it,  that  lu  tlu'  piv^i'iur  of  a  normal  apjietite  and 
anunimpaireil.  ilu:e-ti\-e  capa'  ii\  .  i  In- aiuouin  of  food  should  be  regulated 
entirely  by  the  iuclHuitioiis  oi  the  paiieui .  The  ])Owers  of  digestion  are 
often  greatly  in  excess  of  the  inilii-iiliuns  (ifiordiil  hij  the  aiijietile. 
Therefore,  under  a  properly  direete<l  sysicm  of  siipfraliineutat  lou  imich 
larger  quantities  of  food  may  be  coiisun led  than  suggested  by  the  natural 
desires  of  the  patient.  The  ])i(ii-esM'-  of  absorption  and  assimilation 
ai-e  often  promoted  upon  niodciaie  loicid  leeiling,  with  resulting  gain  of 
appetite  and  weight.  The  stoiiiacji  is  lound  to  respond  astonishingly 
to  the  increased  demands,  and  it  would  appear  that,  with  the  assumption 
of  greater  functional  responsibilities,  the  powers  of  digestion  may  be 
reinforced  to  a  great  extent.  Clinical  observation,  at  least,  conhrms  the 
statement  that,  in  maii\-  cases,  the  appetite  and  digestion  are  notalily 
improved  upon  the  adoption  of  an  intelligent  effort  toward  superalimen- 
tation. This  is  particula.ily  true  among  invalids  with  a  pronounced 
diminution  of  resistance  resulting  from  a  previous  restriction  of  diet. 
It  is  probalile  that  the  .subsequent  ueiu  ral  improvement  is  contribu- 
tory in  part  to  the  gain  in  the  digesti\c  lunctioii. 

There  should  l)e  recognized  the  necessity  ol  inii)oitant  niodilic.ations 
of  the  principle  of  overfeeding,  even  thoiigli  ajipei  iie  and  diucstien  remain 
apparently  unimpaired.  It  is  mamfestly  impiopei'  to  urge  the  inges- 
tion of  an  inordinate  amount  of  food  after  the  loss  of  weight  has  lieen 
satisfactorily  overcome.  With  increasing  gain  in  nutrition,  particularly 
if  this  is  in  excess  of  the  normal,  greater  caution  must  be  exercised. 
It  must  not  be  assumed.  liowe\-er.  that  because  the  invalid  has  sur- 
passed hispre\ioiis  niaxiniuni  weight,  tlie  necessity  for  generous  alimen- 
tation has  ceased  to  exist .  The  in(li:-a,tioiis  for  cessation  of  overfeeding 
are  not  dependent  altogether  upon  the  -ain  in  body  weiglit,  but  also 
upon  the  state  of  the  diucstion  ami  (  irciilation,  and  the  degree  of 
improvement  noted  in  the  pulmonary  condition.  I'at  ieiits  who  are 
loath  to  engage  in  an  etton  \n  ini|ii(i\e  nutriiion.  should  nevertheless 
be  encouraged  to  perscNeic  caiiiiou:  |y  with  a  Liueidus  dieta.ry,  particu- 
larly when  the  weight  continues  dispropml  innately  light  in  comparison 
with  the  height  and  when  at  variance  with  laniily  characteiistics. 

It  is  important  in  all  cases  to  considei-  carefully  tin-  tastes  of  the 
patient,  the  variety  and  character  of  tlu^  food,  the  manner  of  cooking, 
and  the  style  in  which  it  is  served.  Through  the  powi'r  of  suggestion 
by  the  nur.se  or  attendant,  coupled  with  the  exercise  ol  extreme  care  in 
the  preparation  of  the  food,  patients  are  frequ(;iitl\  enabled  to  over- 
come their  natural  repugnance  for  certain  articles. 

In  perfecting  a  system  of  superalimentation,  much  depends  upon 


644  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

the  habits  and  customs  of  the  individual  in  respect  to  the  nature  and 
variety  of  food.  It  is  often  difficult  to  develop  the  habit  of  partaking 
generously  of  meat  among  those  previously  unaccustomed  to  its  con- 
sumption. In  the  same  way  patients,  as  a  rule,  do  not  incline  favorably 
to  the  ingestion  of  fats  and  carbohydrates,  provided  this  has  not  been 
in  accordance  with  former  habits.  In  various  parts  of  the  United  States 
marketl  differences  exist  as  to  the  manner  of  food  preparation.  In 
h(';tlth  resorts,  patients  from  widely  remote  localities  are  observed  to  be 
exieediniily  susceptible  to  radical  changes  in  food  selection  and  method 
of  cooking.  Under  such  circumstances  it  is  the  height  of  folly  to  ignore 
the  logic  of  previous  habits,  and  resort  to  coercive  measures  in  an  effort 
to  secure  the  ingestion  of  sufficient  food.  Whenever  possible  an  effort 
should  be  made  to  cater  to  the  peculiarly  capricious  appetite  of  the  pul- 
monary invalid,  as  viands  unappetizing  to  some  are  found  savory  and 
delectable  to  others. 

Appetite  and  digestion  are  materially  aided  by  the  attractiveness  of 
the  food  and  the  daintiness  with  which  it  is  served.  Cleanliness  of  dishes 
and  linen,  and  absence  of  food  remnants  are  important  considerations. 
Patients  should  not  be  permitted  to  partake  of  their  meals  when 
exhausted  from  physical  exercise,  or  during  a  state  of  mental  or  ner- 
vous excitement.  At  such  times  rest  before  the  meal  is  imperatively 
indicated.  In  many  instances  patients  do  far  better  if  permitted  to  eat 
by  themselves,  thus  avoiding  the  confusion  and  excitement  incident  to 
the  presence  of  members  of  the  family  or  other  pulmonary  invalids. 
In  some  cases,  however,  a  greater  amount  of  food  is  ingested  if  invalids 
are  privileged  to  enjoy  a  pleasant,  non-exciting  social  atmosphere  at 
mealtime. 

Aside  from  these  well-recognized  principles  the  degree  of  success 
attained  in  the  effort  toward  heroic  feeding  depends  largel_v  upon  the 
personal  influence  of  the  nurse.  The  physician  may  emphasize  ever 
so  clearly  the  necessity  of  overfeeding,  and  invalids,  in  appreciation 
of  this,  may  recognize  full  well  that  a  large  measure  of  the  responsibility 
rests  directly  upon  themselves,  yet  it  may  happen,  from  various  causes, 
that  they  are  unable  to  take  unaided  a  proper  quantity  of  food.  Depres- 
sion of  spirits,  temporary  excitement,  or  fatigue,  with  weakened  will- 
power, may  suffice  to  render  the  meal  a  failure.  It  is  here  that  the  use- 
fulness of  the  trained  nurse  is  very  apparent.  Through  the  various 
means  at  her  command,  according  to  tactful  judgment  and  the  exi- 
gencies of  the  case,  she  should  be  able  to  exercise  an  influence  which 
may  often  turn  failure  into  success.  Her  power  may  consist  of  quiet 
persuasion,  exhortation,  or  command,  but  the  result  is  the  same  in  any 
instance.  The  attendant  should  be  taught  to  employ  all  these  mea- 
sures when  necessary,  and  failure  to  enforce  the  ingestion  of  a  satisfac- 
tory meal  should  not  be  overlooked  save  in  the  presence  of  fever,  acute 
digestive  cUsturbance,  or  other  equally  sufficient  cause. 

A  systematic  endeavor  must  be  made  to  determine  the  limit  of 
tolerance  for  each  individual,  who  should  be  compelled  to  consume  a 
satisfactory  quantity  of  food,  not  according  to  his  own  ideas,  but  as 
ascertained  by  judicious  experiment  and  close  clinical  observation.  It 
is  remarkable  to  what  an  extent  patients,  who  at  first  protested  their 
utter  inability  to  take  more  than  a  modicum  of  nourishment,  are  finally 
enabled  to  ingest  a  generous  quantity  of  food. 

The  conclusion  is  logical  that  the  obligation  of  the  physician  to  the 


REGULATION    OF    DIET  645 

patient  is  not  met  by  the  formal  perfunctory  statement  that  it  is  neces- 
sary to  eat  large  quantities  of  food,  nor,  stUl  further,  by  specifying  the 
amount  to  be  taken.  His  trust  is  not  discharged  untU  the  patient  is 
placed  in  such  an  environment,  and  surrounded  by  such  influences  as 
will  secure  compliance  with  detailed  instructions  regarding  the  food. 
The  attainment  of  successful  results  depends  not  alone  upon  the  advice 
received  by  the  patient,  nor  entirely  upon  his  ready  acquiescence,  but 
rather  upon  the  fortunate  acquirement  of  such  combined  conditions  as 
will  insure  the  actual  fulfilment  of  dietary  directions. 

It  is  hardly  necessary  to  specify  in  detail  tlic  chai'artoi-  of  the  food, 
which  is  necessarily  subject  to  much  vuvialiou  in  indix  idnal  cases,  the 
central  thought  being  to  have  the  patient  (■(insume  us  imich  as  can  be 
assimilated.  It  is  well,  however,  to  state  briefly  the  considerations 
leading  to  selection  of  diet  in  the  absence  of  acute  conditions  or  digestive 
disturbance. 

The  policy  of  overfeeding  embraces  a  careful  supervision  of  the  food 
eaten  during  the  meal  and  the  nourishment  taken  at  other  times.  The 
fullest  measure  of  success  can  be  obtained  only  through  a  .special  effort 
toward  the  selection  of  such  varied  articles,  as  will  appeal  to  the  appetite 
and  cater  to  the  desires  of  patients  who  are  admittedly  whimsical.  In 
the  absence  of  digestive  or  eliminative  conditions  clearly  contraindicative 
of  heroic  feeding,  the  patient  should  be  urged  to  ingest  progressively 
increasing  quantities,  being  subjected  at  all  times,  however,  to  close 
clinical  oloservation.  Generally  speaking,  pulmonary  invalids  should  be 
encouraged  to  partake  of  a  mixed  and  unlimited  diet,  with  instructions 
to  use  butter  and  cream  fi-eely.  No  attempt  need  be  made  to  restrict 
the  character  or  quantity  of  the  food  unless  in  accordance  with  special 
indications.  It  is  desirable  that  the  invalid  should  consume  lean  and 
fat  meats,  vegetables  of  all  kinds,  farinaceous  articles  of  food,  fruits, 
nuts,  and  generous  quantities  of  milk  and  eggs. 

For  breakfast  there  may  be  given  sliced  oranges,  grape-fruit,  cante- 
loupe,  baked  apple  with  cream,  stewed  prunes  with  cream,  and  other 
fruits  in  season;  beef-steak,  chops,  chicken,  soft-boiled  eggs  with  bacon, 
eggs  scrambled,  poached,  or  in  omelet,  choice  ham,  or  occasionally  a 
well-prepared  meat  hash;  buttered  toast,  hot  rolls  or  muffins,  corn  or 
wheat  cakes,  and  waffles;  tea,  coffee,  or  cocoa,  and  one  or  two  glasses  of 
milk. 

Dinner  may  consist  of  raw  oysters  or  clams;  a  well-seasoned  soup, 
i-  €.,  vegetable,  turtle,  chicken,  beef,  mutton,  or  fish,  puree,  as  a  rule, 
being  less  desirable  than  consomme  or  broth.  Fish  <if  almost  any  kiiul, 
with  potato  and  green  peas,  roast-l)eef,  lamb  or  million,  cliickm.  luikoy, 
duck,  or  other  varieties  of  game  or  birds,  potato,  baked,  lioilcil,  niashcd, 
French  fried,  lyonnaise,  or  served  in  cream;  spinach,  striiri-licans,  sweet 
corn,  asparagus,  squa.sh,  or  other  vegetables,  in  addition  to  niaiaioni 
prepared  in  various  ways;  lettuce,  tomato,  asparagus,  or  fruit  salad 
prepared  with  a  generous  quantity  of  oil;  crackers  and' cheese;  rice  cus- 
tard or  pudding,  ice-cream,  blanc-mange,  or  other  light  dessert;  two 
glasses  of  milk. 

Food  partaken  in  the  latter  part  of  the  day  should  be  somewhat 
lighter  in  character  and  less  in  quantity  than  that  constituting  the 
midday  meal.  There  may  be  served  a  steak  or  chop,  cold  roast-beef, 
lamb,  tongue,  boiled  ham,  chicken  or  turkey,  fish  and  oysters  prepared 
in  various  styles,  potatoes,  hashed  brown,  baked,  or  mashed;  eggs  in 


616  PROPHYLAXIS,    GEXERAL    AXD    SPECIFIC    TREAT.MEXT 

au\-  form;  buttered  toast,  hot  rolls,  or  muffins;  fruit  or  berries  with 
cream;  tea  and  two  glasses  of  milk. 

As  far  as  extra  nourishment  is  concerned,  it  is  desirable  to  introduce 
as  much  concentrated  food  as  is  practicable,  with  the  least  resulting 
impairment  of  appetite  and  disturbance  of  digestion.  My  practice 
is  to  administer  from  two  to  four  ounces  of  beef-juice  immediately  upon 
awakening  in  the  morning.  This  better  eualjles  the  patient  to  undergo 
the  bath,  and  does  not  interfere  with  the  appetite  for  breakfast,  which 
is  served  one  hour  later.  The  beef-juice  is  repeated  in  the  middle  of  the 
forenoon,  afternoon,  and  evening,  and  constitutes  the  only  nourishment 
permitted  between  meals.  Being  of  small  bulk,  it  has  not  been  found 
to  impair  the  appetite  for  the  ensuing  luncheon  or  dinner.  It  has  been 
my  almost  invarial:)le  experience  that  if  considerable  quantities  of  food 
in  the  shape  of  raw  eggs  and  cream  are  taken  between  meals,  the  sub- 
sequent appetite  is  destro.yed  to  a  great  extent.  Thus  the  patient 
may  be  able  to  take  in  the  twenty-four  hom-s  actually  less  food  than 
if  there  had  been  no  attempt  in  the  way  of  extra  nourishment.  This 
unfortunate  result  rarely  occurs  if  the  eggs  and  cream  are  taken  imme- 
diatehj  following  the  meal.  It  must  be  made  clear  that  extra  nourish- 
ment should  not  be  taken  as  a  substitute  for  even  a  portion  of  the  regular 
food,  but  should  be  entirely  supplementary  to  it. 

After  the  invalid  has  eaten  all  that  can  be  comfortably  consumed, 
it  is  surprising  how  simple  is  the  ingestion  of  raw  eggs  and  cream,  and 
with  what  beneficent  results,  provided  they  are  taken  in  the  proper 
manner.  The  eggs  should  be  swallowed  whole  with  a  little  sherry, 
lemon-juice,  or  ice-water.  In  this  manner  they  are  introduced  into 
the  stomach  without  any  special  taste,  and  do  not  become  repugnant 
to  the  patient  already  satiated  by  a  generous  meal.  Difficult  as  the 
feat  of  taking  raw  eggs  may  at  first  be  considered  bj-  the  invalid, 
it  speedily  becomes  an  unobjectionalile  routine  procedure.  Under  no 
circumstances  are  the  eggs  to  be  beaten  or  mixed  with  cream  or  milk. 
If  incorporated  into  a  palatalile  beverage,  they  eventually  become  dis- 
ta.steful  and  nauseating,  while  if  without  special  flavor  and  swallowed 
quickly,  they  may  be  continued  almost  indefinitely.  The  average 
number  of  raw  eggs  at  present  consumed  by  my  patients  daily  is  from 
six  to  eight,  but  the  necessity  for  careful  individualization  is  very 
apparent.  Immediately  following  the  eggs,  half  a  glass  of  cream  is 
ingested.  To  some  patients  somatose  in  teaspoonful  doses  is  given 
three  times  a  day,  either  in  soup  or  in  the  beef-juice.  Often  emulsions 
of  easily  digested  fats  are  taken  one-half  hour  after  each  meal.  In 
very  desperate  cases  it  is  my  practice  to  take  advantage  of  every 
opportunity  for  the  administration  of  nutritive  enemata,  consisting  of 
beef-juice,  a  beaten  egg,  and  peptonized  milk. 

Alcohol,  although  admittedly  a  food,  is  permitted  but  sparingly, 
and  then  only  in  the  presence  of  clear  therapeutic  indications.  It  rarely 
is  given  as  a  cardiac  or  general  stimulant,  save  to  people  of  advanced 
age.  Used  indiscriminately,  it  adds  to  arterial  excitement,  increases 
the  tendency  to  hemorrhage,  impairs  appetite,  and  promotes  restle.ssne.ss 
and  insomnia.  The  detection  of  its  odor  upon  the  breath  or  the  flushing 
of  the  face  may  be  regarded  as  a  direct  indication  of  its  harmful  effect. 
When  used  in  sufficient  quantity  to  destroy  the  appetite  and  retard 
digestion,  the  amount  of  food  supplied  by  the  alcohol  is  far  less  than 
the  nutritive  value  of  the  food  ordinarilv  taken.     To  the  diminished 


REGULATION    OF    DIET  647 

food-supply  occasioned  by  the  alcohol  in  inordinate  amounts  is  added 
the  distmctly  injurious  effect  of  overstimulation.  Its  intelligent  admin- 
istration, however,  in  small  doses,  and  to  carefully  selected  cases,  may 
be  attended  by  considerable  benefit.  It  is  sometimes  well  to  permit 
those  with  fickle  appetite  to  take  a  mild  dry  cocktail  five  or  ten  minutes 
before  the  midday  or  evening  meal,  but  this  should  not  be  continued 
for  any  great  length  of  time.  If  taken  cold,  only  for  such  periods  as 
advised  by  the  physician,  it  may  add  to  the  consumption  of  food.  A 
light  ale,  stout,  or  "half-and-half"  consumed  with  the  meals  is  of  some 
value  as  an  appetizer  and  an  aid  to  nutrition.  Taken  during  the 
evening,  it  is  frecjuently  found  to  promote  sleep.  Occasionally  a  sherry, 
Rhine  wine,  or  Moselle  may  be  served  with  the  dinner.  This  consti- 
tutes the  only  manner  of  administration  of  alcohol  which  should  be 
permitted,  save  in  the  presence  of  acute  conditions  demanding  active 
stimulation. 


CONTRAINDICATIONS  FOR  EXCESSIVE  FEEDING 

Important  modifications  of  diet  are  demanded  by  the  existence 
of  marked  temperature  elevation  and  by  the  development  of  digestive 
or  kidney  disturbance. 

Fever  from  any  cause  should  constitute  an  insuperal^le  objection 
to  the  general  practice  of  superalimentation.  The  degree  of  restriction, 
however,  is  largely  dependent  upon  the  height  and  persistence  of  the 
fever,  its  immediate  cause,  and  the  varying  associated  conditions.  A 
temiserature  elevation  of  101°  F.  or  more,  irrespective  of  its  source,  is 
almost  always  accompanied  by  a  perceptible  diminution  of  appetite  and 
impairment  of  digestive  power.  At  such  a  time  solid  food  administered 
in  excess  of  the  capacity  for  assimilation  is  worse  than  useless,  often 
being  productive  of  anorexia,  pain,  vomiting,  intestinal  flatulence,  antl 
diarrhea.  In  addition  to  such  chsturbances  engendered  by  an  injudi- 
cious diet  in  the  presence  of  fever,  an  unnecessary  burden  is  placed  upon 
the  entire  digestive  organism,  resulting  in  occasional  strain  upon  the 
heart,  with  acceleration  of  pulse. 

It  is  believed  by  some  clinicians  that  moderate  fever  in  the 
neighborhood  of  102°  F.  affords  no  especial  contraindication  for  forced 
feeding.  The  contention  is  even  made  that  under  such  circumstances 
the  amount  of  solid  food  should  at  once  be  reinforced,  in  the  hope  of 
improving  the  general  condition  through  increased  nutrition.  Such 
practice  is  based  upon  the  assumption'  that  gain  in  weight  constitutes 
an  important  factor  in  the  control  of  an  obstinate  pyrexia  by  virtue 
of  the  added  resistance  to  toxins,  which  is  supposed  to  accrue  from 
improved  nutrition.  Apparently  the  advocates  of  a  full  dietary  for 
fever  patients,  in  the  hope  of  thereby  overcoi  ling  excessive  temperature 
elevation,  do  not  take  sufficient  cognizance  of  the  fact  that  the  digestive 
functions  are  greatly  impaired  by  the  veiy  toxin  responsible  for  the 
fever.  Thus,  upon  the  merits  of  the  defective  assimilation,  the  logical 
demand  is  for  less  rather  than  for  more  footl.  The  food  require- 
ments of  such  patients  are  better  satisfied  by  the  ingestion  of  only 
such  quantities  and  varieties  as  are  capable  of  complete  metabolism. 
Further,  it  should  be  understood  that  the  preeminent  desideratum  under 
such  conditions  is  not  the  immediate  improvement  of  nutrition,  but  the 
primary  reduction  of  jever.     For  the  latter  purpose  other  agencies  are 


648  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

available  of  far  greater  value  than  even  a  successful  effort  to  increase 
weight. 

The  influence  of  rest,  fresh  air,  and  specific  medication  in  the  abate- 
ment of  fever  are  elsewhere  described.  In  this  connection  the  relation 
of  food  and  fever  is  to  be  considered  not  upon  the  basis  of  a  theoretic 
assumption  concerning  the  possible  reduction  of  temperature  through  a 
large  clietary,  but  rather  is  to  be  reviewed  from  a  practical  regard  for  the 
known  inhibitory  action  of  fever  upon  digestion  and  assimilation.  In 
other  words,  experience  has  taught  a  more  wholesome  respect  for  the  un- 
favorable influence  of  fever  upon  food  metabolism  than  for  the  beneficial 
effect  of  superalimentation  upon  an  elevated  temperature.  Prolonged 
recourse  to  an  excessive  dietary  in  the  presence  of  continued  fever  is 
less  likely  to  be  followed  by  a  successful  issue  than  is  a  discriminating 
effort  toward  a  proper  minimizing  of  food-consumption.  Among  patients 
of  this  class  the  ultimate  gain  of  body  weight,  if  secured,  is  determined 
not  so  much  by  a  persistence  of  the  heroic  feeding,  as  by  subsidence  of 
the  fever.  In  a  very  large  number  of  cases  this  symptom  represents 
the  single  decisive  feature  of  the  entire  struggle  against  the  disease. 
With  the  disappearance  of  fever,  nutrition  may  rapidly  improve,  even 
despite  the  ingestion  of  a  diminished  quantity  of  food,  although,  as  a 
rule,  appetite  and  digestion  are  enhanced  so  materially  that  but  little 
difficulty  is  experienced  in  administering  a  generous  allowance. 

While  clinical  observations  point  to  the  inadvisability  and  futility  of 
ruthlessly  engorging  the  consumptive  during  the  existence  of  high  fever, 
it  is,  nevertheless,  true  that  larger  quantities  of  food  should  be  given  the 
pulmonary  invalid  than  to  sufferers  from  other  diseases  exhibiting  the 
same  degree  of  temperature  elevation.  Obviously,  the  administration 
of  solid  food  in  generous  amount  would  be  imperatively  contraindicated 
in  typhoid  fever  or  pneumonia  attended  by  a  temperature  of  102°  F., 
but  it  does  not  follow  that  the  nourishment  of  the  consumptive  should 
be  similarly  restricted  at  all  hours  of  the  day.  Save  in  the  presence 
of  acute  tuberculosis  or  inflammatory  processes,  the  malady  is  essen- 
tially chronic  and  wasting  in  character,  as  opposed  to  diseases  of  self- 
limited  duration.  Moreover,  the  elevation  of  temperature  is  rarely 
continuous  during  the  entire  twenty-four  hours,  the  morning  remissions 
in  the  majority  of  non-acute  cases  permitting  the  ingestion  of  consider- 
able quantities  of  solid  food  once  or  twice  daily. 

While  it  is  desirable  that  no  heavy  meal  be  eaten  at  a  time  of  tem- 
perature elevation,  it  is  frequently  possible  to  administer  a  hearty 
breakfast  and  a  moderately  generous  middaj^  meal  to  patients  exhibit- 
ing an  afternoon  fever  of  101°  to  103°  F.  The  character  of  the  food 
given  at  such  times  need  not  differ  materially  from  that  already 
described  for  pulmonary  invalids  in  general,  the  essential  consideration 
being  the  selection  of  highly  nutritious  and  easil_y  digestible  articles, 
prepared  in  most  appetizing  form.  Duiing  the  latter  part  of  the  day, 
after  the  rise  of  temperature,  the  food  should  consist  principally  of 
liquids,  milk  being  freely  supplied,  together  with  raw  eggs,  beef-juice, 
broths  or  soups,  and  specially  prepared  foods,  as  somatose  or  tropon. 
Under  these  circumstances  it  is  an  excellent  plan  to  give  the  food  in 
small  quantities  at  frequent  intervals,  but  irith  the  utmost  punctuality. 
This  method  of  procedure  may  be  continued  until  the  patient  falls 
asleep  for  the  night.  Upon  awakening  at  subsequent  intervals  it  is 
desirable  to  utilize  the  opportunity  afforded  for  reinforcing  the  nourish- 


REGULATIOi\    OF    DIET  649 

ment,  by  giving  once  or  twice  during  the  night  a  glass  of  milk,  a  raw 
egg,  or  a  portion  of  beef-juice. 

In  acute  cases  with  rapidly  extending  infection,  accompanied  by  con- 
stant high  fever  and  other  severe  constitutional  disturbance,  the  indica- 
tions point  conclusively  to  the  expediency  of  a  simple  diet  consisting  of 
milk  or  other  liquids.  The  administration  of  two  or  three  quarts  of  milk 
daily  with  six  to  ten  ounces  of  beef-juice  and  three  drams  of  somatose 
represent,  if  properly  digested  and  assimilated,  sufficient  caloric  energy 
to  retard  tissue  waste  for  a  temporary  period,  with  a  minimum  burden 
to  the  digestive  organism. 

Independent  of  fever,  disorders  of  digestion,  with  or  without  asso- 
ciated kichiey  disturbance,  may  assume  such  proportions  as  to  demand 
importr.nt  modifications  of  diet.  It  is  not  sui'prising  that  the  functional 
po./er  of  the  organs  concerned  in  digestion,  assimilation,  and  elimination 
should  show  clinical  evidence  of  impairment,  in  view  of  the  toxemia, 
the  malnutrition,  the  general  exhaustion,  the  lack  of  exercise,  the  non- 
adaptability  of  the  food,  and  the  development  of  psychoneuroses.  The 
various  symptoms  of  digestive  derangement  may  be  exhibited  in  the 
entire  absence  oi  pathologic  lesions  of  the  stomach  or  intestine,  as  well  as 
in  connection  with  definite  structural  change.  It  is  also  quite  remarkable 
that  severe  dyspeptic  disturbance  may  take  place  in  the  midst  of 
normal  gastric  secretions,  as  shown  by  repeated  analyses. 

The  organic  changes  responsible  for  the  development  of  symptoms 
referable  to  the  digestive  apparatus  may  consist  of  acute  or  chronic 
catarrhal  conditions,  dilatation  or  prolapse  of  stomach,  passive  conges- 
tion, and  finally  of  actual  tubercle  deposit.  In  addition  to  a  diminished 
motor  power  of  the  stomach  the  chsturbance  of  function,  as  determined 
by  gastric  analysis,  may  partake  either  of  a  hypochlorhydria  or  hyper- 
chlorhydria.  As  a  general  rule,  incipient  cases  present  but  slight  devia- 
tion from  average  individuals  as  regards  the  character  and  sufficiency  of 
stomach  secretions.  In  advanced  cases,  while  hydrochloric  acid  is  occa- 
sionally found  in  excess  of  the  normal,  the  reverse  is  far  more  frequently 
true.  Dyspeptic  cases  exhibiting  symptoms  of  profound  functional  im- 
pairment, without  demonstrable  abnormality  of  stomach  secretions,  are 
usually  victims  of  a  greater  or  less  degree  of  general  nervous  disturbance. 
Among  patients  who  are  anemic,  ill  nourished,  and  psychoneurotic,  it  is 
inevitable  that  digestive  complaints  must  take  their  place  in  the  train  of 
nervous  disorders. 

A  considerable  proportion  of  the  digestive  derangements  observed 
among  consumptives  without  fever  or  obvious  structural  change  in 
the  abdominal  viscera  are  of  undoubted  nervous  origin.  As  a  general 
rule,  the  complaints  made  by  tuberculous  sufferers  from  indigestion 
bear  no  relation  to  the  extent  or  character  of  the  pulmonary  involve- 
ment, which  in  many  instances  is  comparatively  insignificant.  The 
consideration  of  prime  importance,  therefore,  in  such  cases  is  the  per- 
severing effort  toward  an  amelioration  of  the  functional  disturbance. 

Among  the  symptoms  more  frequently  presented  are  obstinate 
loss  of  appetite,  occasional  pyrosis,  distress  in  stomach  or  bowels 
shortly  after  eating,  and  constipation.  The  impairment  of  appetite 
suggests  a  definite  repugnance  for  food  of  any  description.  The  anor- 
exia is  often  confirmed,  not  only  by  the  protests  of  patients  as  to 
their  inability  to  swallow  food,  but  also  by  the  prompt  occurrence  of 
nausea  and  vomiting.     This  is  not  infrequently  of  sudden  onset,  taking 


boU  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

place  in  the  very  midst  of  a  forced  meal.  It  is  not  uncommon  for 
afebrile  pulmonaiy  invalids  in  advanced  stages  to  eat  a  portion  of  the 
food  without  discomfort,  and  often  with  apparent  relish,  only  to  suffer 
a  distressing  interruption  by  the  onset  of  vomiting  unannounced  by 
nausea.  This  sudden  and  untimely  manifestation,  unpreceded  by 
precautionary  warning,  is  of  unquestionable  reflex  origin,  being  induced 
in  many  cases  by  cough,  and  in  others  by  eructations  of  gas  from  the 
stomach.  In  either  event  reflex  irritability  is  a  factor  of  pronounced 
import.  The  sensation  of  nausea,  if  recognized  during  the  taking  of 
food,  demands,  at  least  for  the  time  being,  an  immediate  suspension  of 
nourishment.  After  resting  quietly  in  the  recumbent  position  for  ten 
or  fifteen  minutes,  the  invalid  is  often  enabled  to  resume  the  meal,  and 
persist  to  a  successful  conclusion  without  recurrence  of  nausea. 

Many  patients  complain  of  a  disagreeable  feeling  of  abdominal  disten- 
tion after  eating,  without  actual  nausea.  This  may  occasionally  amount 
to  a  definite  sensation  of  pain,  usually  appreciated  in  the  lower  part  of  the 
abdomen.  Complaint  may  be  made  of  either  constipation  or  diarrhea, 
frequent  headaches,  general  lassitude,  disturljed  sleep,  and  bad  taste 
in  the  mouth,  the  tongue  often  being  furred  and  the  breath  offensive. 
Under  circumstances  such  as  these  modifications  of  diet  for  pulmonaiy 
invalids  become  an  imperative  necessity. 

In  view  of  the  nervous  element,  which  so  frequently  predominates, 
it  should  be  borne  in  mind  that  the  regulation  of  food  for  such  patients 
constitutes  but  a  part  of  the  general  scheme  of  rational  therapeusis. 
Recourse  should  be  taken  to  the  power  of  suggestion,  rest  strictly  en- 
joined, and  special  attention  devoted  to  the  details  of  environment.  As 
the  general  tone  of  the  system  is  promoted  through  the  influence  of 
physical,  nervous,  and  mental  repose,  a  proportionate  improvement  of 
appetite  and  digestion  will  take  place.  The  efficacy  of  these  factors  is 
equal,  if  not  superior,  to  the  benefits  derived  from  restriction  of  diet.  It 
is  incumbent,  however,  upon  the  physician  to  .so  adjust  the  nourishment 
as  to  enhance  the  appetite,  if  pos.sible,  and  conciliate  the  digestion  with- 
out too  great  sacrifice  of  weight  and  strength.  To  this  end  digestive  dis- 
turbances should  be  treated  not  so  much  by  diminishing  greatly  the  total 
quantity  of  food,  but  rather  by  its  judicious  selection  and  time  of  admin- 
istration. 

An  exclusive  liquid  diet  is  often  udxantageous  during  the  first  few 
days,  but  should  be  reinforced  li>'  f;i>il\  diiicstible  solid  food  as  soon  as 
practicable.  Milk  constitutes  an  iniiMutaut  article  of  diet  for  pulmonary 
invalids,  and  is  borne  exceedingly  well  li>  the  majmity  of  patients.  While 
admittedly  productive  of  digestive  (Icraii'^cinint-  in  a  few  exceptional 
cases,  the  vast  majority  of  patients  cmikiuu  ;i  disinclination  to  milk, 
are  enabled,  by  means  of  firm  but  gentle  persuasion,  to  overcome  their 
natural  repugnance.  In  intractable  cases  it  may  be  peptonized  or 
diluted  with  seltzer  or  other  sparkling  water.  Prolonged  adherence  to 
the  so-called  "milk  cure"  is  of  extrenich'  ddulitful  utility.  To  supply 
the  deficit  in  carbohydrates  and  protei<l>.  it  i>  dc-iial'li'  tn  aild  cautiously 
to  the  dietary  raw  eggs,  lieef-juice.  soiii.iin-c,  -<mi|)-,  lnoths,  oysters, 
squab,  chicken,  fish,  liulu  piiddiuiis.  and  iu<taid>.  with  an  ultimate  trial 
of  lean  meats  and  -luiiilcut  M'm'talilrs.  Swccis.  starciios,  and  fats, 
together  with  fruit  auil  [la-ti-y,  sliduld  be  deni(>d  to  patients  with  diar- 
rheal disturbances,  or  witii  other  evidence  of  gastro-intestinal  indigestion. 
Also  these  should  be  interdicted,  together  with  alcohol  in  any  form,  for 


THE    SCOPE    OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR      651 

those  with  pronounced  uric-acid  diathesis,  the  nitrogenous  foods  usually 
being  productive  of  less  harmful  results  than  the  carbohydrates.  The 
use  of  medicinal  measures  for  the  control  or  alleviation  of  digestive  dis- 
turbances will  be  discussed  in  connection  with  the  treatment  of  special 
symptoms. 

True  progress  in  the  art  of  medicine  is  not  dependent  alone  upon 
the  results  of  laboratory  investigation,  nor  the  acceptance  of  theories 
thus  deduced,  no  matter  how  alluring  or  convincing.  To  the  established 
facts  of  clinical  experience  there  should  be  accorded  an  equal  right  for 
recognition  in  the  endeavor  to  judge  sanely  regarding  the  proper  diet  for 
consumptives  amid  the  present  diversified  state  of  opinion.  From  the 
light  afforded  by  careful  observation,  it  is  clear  that  the  adoption  of  a 
standard  diet  applicable  to  pulmonary  invalids  in  general  is  eminently 
impracticable  and  unscientific. 


CHAPTER   XCIV 


THE  SCOPE  OF  THE  SANATORIUM  AS  A  THERAPEUTIC 
FACTOR 

Throughout  the  preceding  pages  devoted  to  general  considerations 
of  treatment,  an  effort  has  been  made  to  emphasize  the  great  importance 
of  attention  to  detail,  rest,  outdoor  living,  and  superalimentation  as 
the  fundamental  principles  of  management.  It  is  self-evident  that  the 
complete  application  of  these  cardinal  features  is  utterly  impossible 
without  the  maintenance  of  strict  disciplinary  control.  In  fact,  the 
es.sential  prerequisite  for  the  successful  development  of  any  elaborated 
system  of  management  is  found  in  the  rigid  enforcement  of  a  suitable 
regime,  for  which  unusual  facilities  are  afforded  in  special  institutions 
for  consumptives. 

Inspired  by  the  excellent  results  attained  through  the  influence  of 
continuous  autocratic  supervision,  phthisiotherapeutists  have  been  in- 
strumental in  establishing  numerous  sanatoria  in  various  parts  of  the 
world.  Regardless  of  climate,  location,  or  immediate  environment,  the 
primary  function  of  these  institutions  was  thought  by  some  to  relate 
principally  to  the  means  thus  secured  for  insistence  upon  disciplinary 
control.  This  was  made  much  easier  in  sanatoria,  partly  as  a  result 
of  important  details  of  construction.  In  properly  located,  thoroughly 
equipped,  and  well-conducted  institutions,  rest  in  the  open  air,  at  all 
hours  of  the  day  and  in  nearly  all  states  of  weather,  is  permitted  upon 
specially  constructed  verandas,  solaria,  and  sleeping  porches. 

In  view  of  the  opportunities  thus  afforded  for  the  inauguration  of 
a  suitable  method  of  living,  the  idea  has  become  somewhat  prevalent 
that  a  perfected  system  of  regimen  obtains  ojily  within  closed  sanatoria. 
It  is  not  true,  however,  that  the  methods  in  vogue  in  such  closed  resorts 
for  consumptives  are  essentially  different  from  those  frequently  em- 
ployed among  a  similar  class  of  invalids  outside  of  institution  walls.  The 
term  "sanatorium  regime"  should  be  understood  to  apply  merely  to 
the  maintenance  of  a  proper  method  of  living  within  an  institution 


652  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

designed  for  this  special  purpose,  rather  than  to  define  a  radically 
distinctive  method  of  management.  Although  it  is  much  easier  to  exact 
implicit  obedience  within  sanatoria  so  constructed  and  equipped  as  to 
furnish  exceptional  opportunities  for  systematic  management,  yet  by 
dint  of  earnest  effort  on  the  part  of  a  resourceful  medical  attendant,  an 
equally  rational  supervision  can  be  successfully  instituted  elsewhere. 

No  reflection  is  intended  upon  the  great  practical  utility  of  closed 
sanatoria,  but  issue  is  taken  with  the  assumption  of  their  invariable 
necessity  in  order  to  secure  the  fulfilment  of  a  satisfactory  regime.  It 
is  also  insisted  that  the  ample  recognition  accorded  to  such  institutions, 
with  reference  to  their  large  field  of  usefulness,  does  not  justify  a  belief 
in  the  practical  appropriateness  of  sanatorium  life  for  all  cases  of  con- 
sumption. Unfortunately,  the  doctrine  of  sanatorium  control,  which  has 
been  advocated  so  zealously  during  the  past  decade,  has  been  literally 
accepted  by  many  as  the  exclusive  means  of  securing  satisfactory  results. 

In  order  to  minimize  the  evils  resulting  from  extravagant  and  erro- 
neous ideas  entertained  concerning  the  role  of  the  closed  institution  for 
consumptives,  it  is  important  that  the  supporters  of  the  sanatorium 
movement  should  assume  an  eminently  conservative  position.  It  seems 
fitting  to  institute  an  inquiry  as  to  the  precise  scope  of  the  sanatorium 
treatment  of  consumption,  without  bias,  prejuclice,  or  preconceived 
ideas,  save  those  founded  upon  the  substantial  facts  of  experience.  It 
is  not  desired  in  the  merest  way  to  detract  from  the  honor  and  glory  of 
the  early  pioneers  who  devoted  their  lives  to  a  cause  so  worthy,  and 
who  are  destined  to  leave  a  lasting  monument  to  their  ability  and  per- 
sonal sacrifice.  The  movement  for  the  treatment  of  tuberculosis  in 
closed  institutions  originated  with  Bodington.  of  Warwickshire,  Eng- 
land, in  1839.  The  theories  advanced  were  subjected  to  extreme  ridi- 
cule, and  the  promoter  doomed  to  much  personal  disappointment  and 
humiliation.  His  ideas  were  subsequently  championed  by  Herman  Breh- 
mer,  of  Germany,  who,  despite  much  bitter  oppo.sition  and  contumely, 
succeeded  in  establishing  a  sanatorium  for  consumptives  at  Goerbers- 
dorf ,  in  the  Silician  mountains.  Following  the  demonstrated  soundness 
of  Brehmer's  views,  and  stimulated  by  his  example,  several  prominent 
physicians  were  encouraged  to  adopt  similar  methods.  Notable  among 
the  early  followers  were  Dettweiler  and  ^^'alther,  Sir  Herman  Weber,  and 
Trudeau.  In  recent  years  the  sanatorium  idea  has  taken  deeper  root 
than  ever  in  the  professional  and  public  minds,  until  the  outgrowth  has 
assumed  such  proportions  as  to  endanger  its  practical  efficiency  and 
benevolence. 

Though  inspired  by  no  spirit  of  iconoclastic  criticism,  it  is  believed  that 
the  time  is  opportune  for  a  presentation  of  some  negative  phases  of  the 
sanatorium  proposition.  With  no  derogation  of  the  noble  work  per- 
formed by  the  advocates  of  this  method,  the  plea  is  presented  that,  fol- 
lowing their  example  in  its  essentials,  and  profiting  by  their  experience, 
equally  good  results  may  be  accomplished  without  the  aid  of  special 
institutions.  In  this  connection  an  appreciative  acknowledgment 
should  be  made  of  the  peculiarly  beneficent  mission  of  the  sanatorium 
from  the  standpoint  of  public  prophylaxis. 

Attention  has  already  been  called  to  its  humanitarian  scope  and 
economic  value,  as  well  as  to  the  pronounced  educational  influence, 
which  reflects  one  of  its  chief  advantages.  In  appreciation  of  the  great 
usefulness  of  sanatorium  management  for   certain   carefully  selected 


THE    SCOPE    OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR       653 

cases,  it  is  designed  to  discuss  merely  its  medical  scope  for  non-indigent, 
non-hopeless  consumptives,  regardless  of  climatic  location.  Paradoxic 
as  it  may  appear,  the  propositions  are  advanced  that  residence  within  a 
closed  sanatorium  offers  to  a  class  of  cases  the  best  possible  conditions 
to  be  obtained,  and  that  summary  recourse  to  complete  institutional 
regime  is  distinctly  prejudicial  to  the  best  interests  of  others.  These 
differences  pertain  to  such  determining  individual  factors  as  the  financial 
status,  temperamental  peculiarities,  and  domestic  conditions.  Other 
considerations  which  may  justly  obtain  in  certain  instances  are  the 
possible  accommodations  to  be  secured  other  than  institutional,  and  the 
character  of  medical  counsel  to  be  obtained  either  within  or  without 
the  sanatorium. 

The  sole  claim  of  sanatorium  advocates  relates  to  the  degree  of 
success  possible  of  attainment  in  establishing  and  maintaining  a  per- 
fected system  of  disciplinary  regime.  An  unceasing  medical  super- 
vision is  sometimes  necessary  for  the  well-being  of  certain  cases,  while 
an  equal  amount  of  surveillance  is  distinctly  detrimental  to  the  best 
interests  of  others.  A  particular  regard  for  the  minutest  detail, 
either  within  or  without  an  institution,  is  dependent  almost  entirely 
upon  the  solicitous  attention  of  the  physician.  It  is  almost  purely 
a  question  of  personal  equation,  and  demands,  in  addition  to  a  masterful 
familiarity  with  tuberculosis,  a  certain  aptitude  for  the  peculiar  require- 
ments of  the  position,  a  devotion  to  the  work  for  its  own  sake,  an 
interested  regard  for  the  slightest  welfare  of  the  patient,  broad  sym- 
pathy, infinite  tact,  intuitive  perception,  and  unyielding  firmness. 
These  qualities  may  be  utilized  for  the  benefit  of  the  consumptive  with- 
out a  closed  institution,  which  in  most  instances  is  a  valuable  adjuvant 
rather  than  a  sine  qua  non.  It  is  the  man,  not  tlio  institution,  influencing 
the  degree  of  cooperation  and  hearty  goo(l-lcllii\\>liiii  between  physician 
and  clientele,  which  alone  can  insure  a  proju-r  iliM'iiiliuary  control.  By 
as  much  as  it  is  not  the  sanatorium  alone,  but  also  the  attending  physician 
determining  the  influence  for  good,  by  the  same  token  must  it  be  remem- 
bered that  it  is  not  the  disease  to  be  considered  solely,  but  the  invalid 
as  well.  This  presupposes  the  consideration  of  other  factors  than  purely 
medical  or  sociologic  features.  For  the  consumptive  the  question  of 
success  or  failure  frequently  depends  upon  the  aljility  to  adapt  oneself 
to  unusual  conditions,  and  in  this  quality  the  invalid  is  often  found 
deficient.  The  wisdom  of  an  intelligent  modification  or  adjustment 
of  the  immediate  environment  to  satisfy  peculiar  individual  require- 
ments is  readily  apparent.  There  surely  is  not  implied  an  invariable 
necessity  of  confinement  within  sanatorium  walls,  although  this  is  admit- 
tedly desirable  for  many  cases  otherwise  difficult  of  management.  In 
addition  to  intractable  ca.ses,  patients  for  whom  sanatoria  are  particu- 
larly appropriate  are  those  with  such  limited  finances  as  to  preclude 
the  acquirement  of  satisfying  conditions  without  the  benevolent  aid  of 
partially  endowed  sanatoria.  The  founding  of  modest  institutions  of 
this  character,  inoxiilin^  excellent  accommodations  to  worthy  consump- 
tives at  a  mini  III  II  III  nj  i  xjn  /i.sf,  without  ostentatious  display  or  sole  regard 
for  beauty  of  architectural  design,  represents  the  most  substantial  form 
of  true  charity  and  practical  philanthropy. 

It  has  been  asserted  that  the  special  advantages  sometimes  accruing 
from  a  properly  conducted  sanatorium  are  not  altogether  inherent  to  the 
institution  itself.     The  erection  of  imposing  structures  and  the  laying 


654  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

out  of  beautiful  grounds  sometimes  represent  in  themselves  onlj-  the 
taste  and  ambitions  of  the  founders,  rather  than  the  practical  needs  of 
the  inmates.  Ample  porch  accommodations,  with  wise  provision  for 
private  balconies,  rooms  with  sunnj-  exposure,  proper  facilities  for  heat- 
ing and  ventilation,  and  finally  a  generous  tempting  cuisine,  of  vast 
importance  though  they  be,  are  none  the  less  to  be  secured  in  many 
instances  outsideof  closed  sanatoria.  The  attainment  of  suitable  sur- 
roundings and  conditions  is  frequently  most  difficult,  and  imposes  a  seri- 
ous tax  upon  the  time,  energy,  and  perseverance  of  the  medical  atten- 
dant; yet  in  most  communities  this  may  be  accomplished  through  the 
personal  attention  of  physicians  willing  to  recognize  their  obligations 
with  reference  to  such  details. 

Experience  has  taught  that  the  mecUcal  adviser,  if  he  so  elects, 
may  devote  sufficient  supervisory  attention  to  his  patient  outside  an 
institution,  and  through  the  exercise  of  painstaking  effort  may  inaugu- 
rate proper  methods  of  living  somewhat  along  the  same  lines  as  in 
well-regulated  sanatoria.  The  same  well-recognized  principles  may 
be  enforced  upon  a  smaller  scale,  and  freciuently  more  to  the  actual 
advantage  of  the  pulmonary  invalid.  If  detailed  autocratic  super- 
vision, which  in  many  cases  is  admittedly  indispensable  for  the  accom- 
plishment of  the  best  results,  was  the  only  essential  factor  involved  in 
a  question  relating  to  the  lives  of  unfortunates,  the  decision  would  be 
invariably  made  in  favor  of  the  closed  sanatorium  upon  some  remote 
hilltop.  The  fact  remains,  however,  that  to  the  consumptive  there 
.should  be  accorded  a  consistent  regard  for  certain  other  fundamental 
considerations.  In  spite  of  his  bodily  infirmities  he  remains  a  human 
being,  possessing  essential  peculiarities  of  temperament  and  disposi- 
tion of  no  small  significance.  The  factors  inherent  to  the  individual 
are  sometimes  of  more  transcendent  importance  than  the  tuberculous 
infection.  A  problem  of  this  character  cannot  always  be  adjusted  prop- 
erly by  a  summary  recourse  to  its  medical  and  sociologic  aspects.  While 
life  in  a  closed  sanatorium  is  perhaps  more  strictly  in  accordance  with 
the  principles  of  modern  phthisiotherapeutic  thought,  nevertheless,  in 
its  every-day  application  to  special  cases,  its  non-adaptability  is  not 
infrequently  apparent. 

It  may  be  questioned  if  the  uniformly  good  results  which  have  been 
reported,  demonstrating  the  value  of  sanatorium  treatment,  are  depen- 
dent entirely  upon  the  institution.  It  is  fair  to  assume  that  a  consider- 
ation of  vast  importance  relates  to  the  incipient  character  of  the  cases 
admitted  for. treatment.  Rejection  of  invalids  with  advanced  infection 
is  in  accordance  with  the  avowed  jnui^ose  of  nearly  all  sanatorium 
authorities,  who  have  reported  statistical  observations.  It  is,  of  course, 
natural  that,  as  a  rule,  sanatoria  sluiuld  pxtcud  a  welcome  only  to  such 
cases  as  offer  an  eminently  faMnal'lf  ]iiii^iiosis.  At  some  popular 
in.stitutions  it  is  stated  that  patient-  an-  adiiiittedfromthelistoftho.se 
who  have  passed  the  necessary  examination,  not  in  the  order  in  which 
they  have  applied,  but  according  to  their  physical  condition,  the  most 
favorable  ca.ses  being  admitted  first.  A  review  of  the  annual  medical  re- 
ports emanating  from  several  of  the  sanatoria  in  this  country  has  recently 
shown  that  the  condition  is  described  as  favorable  in  an  exceedingly 
large  proportion  of  the  patients.  Digestion  was  unimpaired  in  the 
majority  of  cases  upon  admission,  the  average  maximum  temperature 
being  over  100°  F.  in  a  very  few  instances.    Many  are  reported  to  be 


THE    SCOPE    OF   THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR       655 

without  tubercle  bacilli  upon  arrival.  Nearly  all  cases  were  practically 
devoid  of  important  complications.  In  some  of  the  cases  aclmitted  to 
sanatoria  the  condition  is  of  so  doubtful  a  character  that  the  patients 
are  kept  under  observation  in  order  to  arrive  at  a  definite  diagnosis,  yet 
institutions  both  at  home  and  abroad  are  accepting  but  a  small  propor- 
tion of  the  consumptives  applying  for  admission. 

It  is  difficult  to  understand  how  in(li\'iduals  with  incipiont  infpftion, 
without  temperature  elevation.  ili^c.-ti\c  iniiKUi-mrnt .  mnilici'  (•(unplica- 
tions,  and  frecpiently  without  IniriHi.  cuii  r('(|uiiT  upcm  liic  miTit  -  cii  their 
condition  that  degree  of  medical  attciitidii  nccc-j-itai  mi:  icMdi'iicc  within 
a  closed  sanatorium.  As  regarrls  thd  c  institution  .  h.i  i  lioiiut^-  a  mis- 
cellaneous aggregation  of  con.sumi)ti\('-.  it  wmild  ;i|ii>i';ir  that  the  social 
conditions  could  not  be  such  as  to  promote  the  happiue.s.s  and  content- 
ment of  invalids. 

Aside  from  these  considerations,  which  surely  are  more  substantial 
than  sentimental,  may  be  mentioned  the  value  of  the  psychic  element  to 


Fig.  141. — Summer  residence  used  annually  for  a  group  of  .selected  patients. 

be  observed  from  occasional  judicious  change  of  residence  and  immediate 
surroundings.  This  potent  influence  for  good  is  not  obtainable  under  the 
fullest  interpretation  of  the  so-called  institutional  ri'gime.  As  the  result 
of  some  clinical  study  in  an  effort  to  recognize  essential  facts,  to  apply 
established  principles,  and  to  effect  a  mutual  interada]itation  of  indi- 
viduals to  special  conditions,  <-ert:iiii  (•oncliision--  lia\e  tivadually  assumed 
shape.  The  conviction  has  thus  Ijceii  loiced  thai  for  ni:iii\'  cax's  the  idea 
of  a  home  and  genuine  hv.me  life  is  the  iile.il  >piiit  to  be  lusieicd.  t(JL;etlier 
with  a  judicious  amount  ,.f  medicil  i  out  rol.  If  close  dail\'  snpeiv  i~ioii  of 
early  ca.sesisnot  invari;d>l\-  del  nam  led.  the  medical  uchisei'  may  e\e  rci.se 
sufficient  personal  dire/tiou  over  his  patients,  if  he  su  elects,  in  private 
abodes,  promoting  in  many  cases  the  happiness  and  social  \\elfare  of 
the  invalids.  The  careful  selection  of  a  residence  meeting  all  known 
requirements  as  regards  location,  sunshine,  porch  room,  and  outdoor 
accommodations,  the  wisest  grouping  of  a  chosen  few    with 


656 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


reference  to  coiigenialit}-,  temperamental  peculiarities,  tastes,  stage  of 
the  disease,  and  financial  ability,  the  presence  of  a  competent  housekeeper 
and  nurse,  and  finally  the  directing  influence  of  a  non-resident  medical 
attendant,  must  afford  a  combination  sufficient  to  produce  satisfying 
results.  In  Fig.  141  is  shown  a  summer  residence  peculiarly  adapted 
to  the  needs  of  a  few  patients.  The  house,  octagonal  in  shape,  is  entirely 
surrounded  by  a  screened  porch,  which  is  divided  into  sections  by  inter- 
vening wire  screening  and  adjustable  awnings. 

The  medical  control  should  not  be  permitted  to  predominate  offen- 
sively, but  should  continue  as  a  non-intrusive  factor  in  the  con.stant 
physical  guidance  of  the  temporary  household.  It  seems  unnecessary  to 
more  than  mention  the  improved  psychic  effect  of  such  an  environment, 
which  exercises  a  potent  influence  upon  many  pulmonary  invalids.     In 


this  manner  much  of  the  ennui  and  nostalgia,  with  resulting  general 
depression,  so  frequently  observed  in  institutions,  may  be  effectually 
obviated.  On  the  other  hand,  to  tho.se  previously  unaccustomed  to 
separation  from  home,  sanatorium  sojourn  is  often  utterly  beyond  their 
powers  of  individual  adaptation.  In  pursuance  of  the  foregoing  ideas 
it  has  been  my  custom  for  many  years  to  provide  suitable  accommo- 
dations for  my  patients  in  residences  appropriate  for  varying  clas.ses. 
These  abodes  are  selected  either  on  the  outskirts  of  Denver  or  in  the 
mountains  of  Colorado,  according  to  the  season.  This  grouping  of 
patients,  particularly  during  the  warmer  weather,  in  the  midst  of  new 
surroundings,  has  been  found,  as  a  rule,  especially  advantageous.  As  a 
result  of  the  constant  attendance  of  an  efficient  nurse,  a  suitable  regime 
is  maintained  somewhat  along  the  lines  of  a  cottage  sanatorium.     Some 


THE    SCOPE    OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR       657 


idea  as  to  the  jn'ivatc  ;kt 

afforded  l>\-  rclcrcncr  id  llic  :MTiiin|i;ui 

seekin.i;  cliiiKilic  ud\a.ni:i:ic,-  away   IV 

exceptioiudl\-   inii'a.iiaM"   ra  c  .      Am 

autocratic  coiiti-o|  i>  iu-cnil\-  iiidica.i 

iv-ula,tc(l  saiiaJoila,  l.nii-   I.. mid  ,-ul.s, 

liciicccomliiciw  lo  lic.l   rcsulls.      Tlic  ncccs-il  V  of  .•aivlul  mdi vi.lualiza- 

tiou  IS  thus  apparent,  I  lie  most  suitalilcciiviroiiiiu.nl  lor. .lie  I  ,ciii- (lUlte 

inappropriate  for  another. 

Apropos  of  the  foregoing  considerations,  it  is  of  interest  to  compare 
the  ad\antages  of  the  sanatorium  with  certain  objectionable  features 


patients  of  tliis  class  nuiv  he 
pilot  om-apli.. 

eiide.l  t,.  apply  to  invalids 
..line.  Iiut  ,lo,.,-  11, ,t  n.l,T  to 
Ultients  of  liie  lalter  class, 
ic  n.utiiu.  dccipliiie  <if  well- 
it    to  impli.it    oi.edieiic,.  and 


Fig.  143.— Anottii 


relating  to  the  care  of  ]iulnionarv  invalids  in  health  resorts  when  : 
paniedliymeml.eis,,fil„.imiiie.liatcfamilv.  T'lider  smli  circum- 
obvious  iliflii'uit >■  1  -  ex|ii'i'jeiiced  HI  maii\-  m- t.iiii'e-  111  -eciiriiiu  an 
sphere  of   complete    i-eposi'.       In    a.ddllion.    tlie    coiitmiious    piCM 

factors  ari.se  liy  \'irtue  of  the  I'oiiliici  im;  opimoie-  -omet  imes  euiei 
bvapuront,liii^l>a,nd.or\vif|.  n.-ardiim  ( lie  appropri.a.teiie"  .if  the  i 
and  bvtlie  lack  of  insi-teiice  up., II  i-.n,, unmix  lo  piVMril.e.i  m-tru 
The  phy.-i.'i-m  e^  lik.'lv  t.,  l.e  :,.nouslv  liaJi.li.'app.'.l  1 . v  lli.'  -iuKIm 
and  perver-ity  ol  a.c.'.mipau  viu-  relat  i\-.'s.  wli.ise  temper.'Uiii'iil  al 
arities  ami  di' p..- it  i..ii  m;i\'  di'm.aji.l  the  (li-;pla\-  of  nioiv  l.-u'l.  .lis,' 
and  finiiii..--  than  tli.^  .■.mtr.il  .,f  tlu^  p.ali.^iit.  I'liw  a.iTa.ul  e.l  p 
condoleii.'c.  .,r  m.luluen.'e  i-  ic^ponMl.le  111  many  iiiHa,m-cs  for 
retardation  of  recovery.  Provided  relatives  evince  a  cheerful 
ance  of  the  instructions  detailed  by  the  physician,  it  frequently 


accept- 
follows 


658  PROPHYLAXIS,    GENERAL    AND    SPECIFIC 


TREATMENT 


■c*~^; 


^*o.,  ^^^  %^ 


wmmmmm^^ 


!  -.iM.-  i.iiu-c  as  preceding. 


THE    SCOPE    OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR      659 

that,  despite  their  cordial  acquiescence,  the  patient  is  wont  to  refuse 
to  near  ones  that  implicit  obedience  which  could  otherwise  be  obtained. 
The  influence  of  home  life,  e\en  thrduuh  no  !ic,uli;;ciicc  or  ]ici'V(M-.sity  of 
judgment  on  the  part  of  the  fuiiiily,  is  somctiino  ii's]i(iiisililc  for  unfor- 
tunate laxity  of  discipline.  In  :uiilition  to  the  occasioiia.l  likelihood  of 
physical  or  social  indulLiciicc,  tlic  hours  of  rest  in  the  open  air  are  less 
apt  to  remain  undistiirlicd.  and  the  ingestion  of  food,  upon  the  whole, 
less  satisfactory.  It  is  unnecessary  to  .state  that  the.se  olijections  do 
not  invariably  obtain,  the  efforts  of  the  physician  in  some  eases  lieing 
vigorously  reinforced  by  accompanying  relatives.  In  lunleitakini!,  the 
management  of  pulmonary  invalids,  particularly  serious  cases,  in  pri- 
vate houses,  it  is  desirable  to  .secure  the  services  of  a  forceful,  quiet, 
and  discreet  nurse,  through  whose  tact  and  firmness  there  may  be 
secured  implicit  compliance  with  directions.     Given  an  atmosphere  of 


Fig.  146. — Mountain  residence  with  .sleeping 


d  soutliern  exposu 


repose  and  contentment  in  a  well-(iio>eii  liousr,  satislact<ii-il\' V)i-o\  id 
with  porch  accdinnnxlations  anil  an  al  lUinlaniT  of  apl  ict  i/.ui'j:  lood  p 
pared  in  acconlaiicc  witli  mdix-iilnal  ta  Ir-.  l  he  I'hysician  is  in  a  positi 
to  elaborate  a  lull  c(>iicc|ii  kui  of  in -i  ii  iit  lonal  n'Liiii 
An  important  and  sonicwiial  nculccicd  a-pe 
torium  is  the  possil.U'  role  ot  ,-iicli  in-i  ii  m  ion  : 
research,  but  thi.s  feature,  whiih  i-  rc<'OLini/,cd  a  < 
be  amplified  to  the  fullest  I'xtent  onl\  in  ihose 
by  State  aid.  .\mple  opportunii\'  loi'  oiiiiin.il  la 
should  obtain  in  san.'itoi'i.a  conducted  lor  the  liciicl 

tives.      Upon    the   othi-l'    li.Uid.    ciuuc.-d    oli.-MTWUl 

merit  is  permitted  ont-ide  of  iiisutution-  to  jili^ 
proper  equipment  and  ideals. 

An  economic  phase  of  the  sanatorium  mo\'ement  is  worthy  of  pass- 
ing mention.     It  appears,  from  a  practical  standpoint,  that  more  bene- 


he  closed  sana- 
ers  of  scientific 
iMi-e  \a.lue.  may 

i\  iin-eMmalion 
Imcnt  consump- 
i  hn:li  order  of 
•  possessing  the 


660  PKUPHVLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


Fig.  148.— AiiotLer  view  of  ^aIue  house.     Taking  the  cure  in  the  nimintains. 

fioent  results  may  be  attained  by  the  construction  of  a  greater  number  of 
tuberculosi.s  dispensaries,  and  by  the  more  generous  mamtenance  of  anti- 


THE    SCOPE    OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR       661 

;ui  liy 

im  sli 


avagaiit  sums  of 
i\ato  sanatoria.  The 
111'  o.stensible  purpose 


of  housing  p  Uk  iit--  \\itli  //( 
impairment  wiici  ii<  iiiiou 
apparent       Hit  i  ost  (it -^ud 


licet  Mill   \VI 

lldllt    CdllStitl 

tiiinal 

niiisUndhi 

,i,t-oj-,l,,<,rs  u 

([uite 

sassurudlv 

nit  ol  all  pro) 

(iition 

to  the  benevolent  results.  On  the  other  hand,  at  a  less  expense,  endur- 
ing benefits  can  be  obtained  through  the  establishment  of  modest  dis- 
pensaries.    Protest,  therefore,  should  be  made  against  the  unreasonable 


662 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


expenditure  of  public  money  for  costly  buildings,  which,  in  many  in- 
stances, are  injudiciously  located  in  damp,  moist  regions  or  in  immediate 
proximity  to  large  centers  of  population.  It  frequently  happens  that 
in  proportion  as  the  cost  for  construction  is  excessive,  the  funds  for 


maintenance  are  insuffi 
neiit  sanatoi::i,  iu  IJii^ 
that  no  practical  a,il\:ii 
details  of  collet  I'uct  inn  ( 


odations  upon  three  sides. 

it.  This  is  particularly  true  of  several  promi- 
d  and  America.  It  should  be  emphasized 
:rs  III  the  consumptive  accrue  from  elaborate 
illuous  equipment. 


tage  with  sleeping  porch. 


Despite  ample  facilities  for  the  accommodation  of  tulierculous 
patients  in  England,  the  King's  sanatorium  near  Midhurst  has  lieen 
recently  completed  at   an  approximate  expen.se   of  $1,000,000.      The 


THE    SCOPE 


OF    THE    SANATORIUM    AS    A    THERAPEUTIC    FACTOR      663 


Fig.  154.— "Rock  Rest.' 


outlay  in  many  respects  was  not  strictly  demanded,  yet  no  provision 
was  made  for  the  admission  of  cases  which  were  not  entirely  charitable. 
The  cost  of  the  Beelitz  Sanatorium  near  Berlin  is  even  more  prodigious. 


664 


PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 


Three  million  dollars  have  been  expended  for  its  construction,  with  pro- 
vision, however,  for  600  beds.  It  is  hardily  necessary  to  present  photo- 
graphs of  the  various  sanatoria  in  thi^^  conntrv  and  abroad  in  order  to 
illustrate  the  beauty  of  arcliitiMtui;il  (k">ii:ii  ami  ilir  general  magnificence 
of  construction.  The  niajcuii}  nf  reader.^  arc  already  quite  familiar  with 
the  general  featnresof  American  .-iauatoiia,  the  iin.).->t  modern  of  which  pos- 
.sess  admiiii-traiidii  (iffices  in  close  proximity  to  the  buildings  devoted 
to  the  houMii-  (11  patients.  Private  sleeping  balconies  communicating 
directly  with  aii  inside  chamber  are  provided  almost  invariably,  while 
protection  is  afforded  in  extremes  of  weather  from  the  summer  heat 
and  the  winter  storms.  It  is  important  that  all  rooms  occupied  by  con- 
sumptives should  be  spacious,  sunny,  and  well  ventilated.     These  con- 


siderations are  particularly  important  with  respect  to  a  common  dining- 
room,  ill  \\lii(h  the  air  during  the  winter  sea.son  is  likely  to  become 
noticcaJil}^  I'liiil.  I'cnlio  -liduld  be  constructed  in  nearly  all  available 
phicc^.  e~iie(iall\  111  |ii(iteeteil  coiTiers,  in  Order  that  shelter  may  be 
secured  wlieii  iieee~-ar\  Iniiii  sun,  wind,  snow,  and  rain. 

Waiviiiu   ,iii\    mint  ion   of  climatic   considerations,  it  is  important 
that  due  a.tteiiii 


that  -aliatiMia  ■ 
and  preferabh- 
The  site  for  tlic 


I. II  lie  uiven  to  the  matter  of  location.  If  the  teaching 
ihe  eliicacv  of  fresh  air  is  correct,  it  is  essential  that 
■■nr>\  lor  tlic  cxcliiMve  ai.l  "t"  r.inMunptivcs  sl„,„ld  be 
)  render  tlie  ureale-t  |Mi~-ihle  liellelil.  It  i-  nn|>ortant 
i.Mlld  l.c  located  apart  Inmi  .Icn-ely  populated  .listricts, 
11  mountainous  regions,  rather  than  upon  the  lowlands, 
nstittition  should  not  be  selected  upon  the  extreme  crest 


THE  SCOPE  OF  THE  SANATORIUM  AS  A  THERAPEUTIC  FACTOR   665 

of  an  ele\atecl  ies:ion  on  k  i  cmnt  ot  tin  (iinicccss:i,i-\- cxixi-urc  to  severe 
winds  Foi  the  same  lei  <>ii  it  lix  itum  iipmi  tin-  uiipinicitccl  ])l;iins, 
paitKuliih  in  the  hij;h(  i  illiludc  is  |i(MMili;ul\'  inuppi-opriatc.  no 
natui  il  shdtfi  l.iin-,  illoidi  dtKiin  xlu  \w:i\  (.fthcMiu  dm  iii.n  the  suniiner 
months  iiid  liuiii  tli(  liiii  iiiiMis  wind  (iccusidinilly  |ii'i'\a.iliii;i  a,l  (itlier 
seasons  (  (  it  uu  ([i-  id\  int  u(  --  iKo  u  riuc  frmn  ]ihicini;  the  Imildings 
in  deep  \  ille\  s  on  k  (  ount  ot  tht  lessei  hours  of  sunshine  and  the  greater 
tendencj  to  dampness  with  infeuoi  diainage.  An  ideal  site  for  a  sana- 
torium 01  in  f^f t  foi  all  buildings  especially  designed  for  pulmonary 
invalids  should  he  upon  the  southern  slope  of  a  hill  or  near  the  base  of  a 
model  iteh  huh  mountain  In  oidei  to  afford  shelter  from  the  prevailing 
winds  th(    biiildinj;s  should  be  located,  according  to  regional  weather 


Fig.  156. — Six-room  cottage,  somewhat  primitive,  but  quite  comfortable 
room. 


conditions,  cither  to  the  east  or  west  of  a  spur -extending  southward. 
It  is  still  ijioi'e  a,dvantaffeous  if  the  mountain  rises  to  a  considcral>le 
distance  in  the  tar  l.a(d<,m-,Miiid,  even  to  a,  lic.i.^hl  of  M.veral  hundred  feet, 
as  shown  in  the  aceoin|ia.n\iiii:  illn-lralion  n\  a,  pri\ate  re-i(l<>nce  (Fig. 
157).  The  soil  dioiild  I.e  ,iry.  poroi,-,  a.nd  ~andy .  all  hmmh  a  rorkv  for- 
mation is  not  nndeHiaJ'le.  I  »ii  aecoinit  of  tJie  necessity  of  irrigation 
in  dry  climate  .  no  elaKoi  ale  aiieinpi  hoiild  lie  made  to  beautify  the 
grounds  by  hiMUL;  oui  expan-JNc  lawns,  or  by  disposing  flower-gardens 
in  the  immediate  \irinit\  of  the  s.^natoiiuMi.  a.lthoudi  such  (unaiiien- 
tation  greatlv  adds  to  the  o;itw-a,rd  att  ract  ixiaiess  of  the  institution. 
Undoubted  benefit  arenies  to  the  pulinonuiv  in\alid  from  a  pleasing 
landscape.  Attracti\-e  \-iews,  combining  lantl  and  sl<y  effect,  contriliute 
to  a  remarkable  degree  in  breaking  an  unceasing  monotony.     Definite 


66G  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


CLIMATE    IN    THE    TREATMEXT 


OF    PULMONARY    TUBERCULOSIS       667 


summer  cottages. 


inspiration  und  elevation  of  spirits  are  not  infrequently  afforded  liy  tlie 
sublimity  of  scenic  grandeur  witnessed  in  mountain  resorts.  In  Fig.  158 
is  shown  the  delightful  view  afforded  from  the  porches  of  cottages  for 
consumptives  at  Estes  Park,  C'oloi-ado. 


CHAPTKP.    X('\' 


THE  ROLE  OF  CLIMATE  IN  THE  TREATMENT  OF  PUL- 
MONARY TUBERCULOSIS 


Is  . 

chaptci 
regard  1 


was  1) 
■  fresh 


tm 


sion  has  .•ippcarcd  tha.ii  l.clicf  in  the  ,m|ikiI  suil  .-iI  ulil  \'  of  all  cliniates 
for  the  liKUiugeliicliI  ni  tiilH.|vii|,,s|s,  Allli(Hi,-li  llir  siil.slamKil  value 
of  certain  cinnliiiicd  a,l  iiinsiiliciac  a,t  t  rilniles  chara.i  leri-t  ic  ol'  localities 
has  been  recognized  IVom  the  earlie-t  (la,\-  n\  niedicine.  and  ciml  iniiously 

attested  by  the   irre>i>tiMe    loi^n-    of   .■linical    i>\|ieneii.-e.    a   - 'what 

bitter  iconoclasm  has  lieeu  exliilnted  in  late  ye.ais  ((luceiinni;  the 
beneficial  influence  of  climate.  There  has  I'sen  an-en  a  tendem  y  to 
renounce  completely  its  value  as  a  therapentir  ia(  toi.  the  oppdnents 
offering  the  contention  that  an  open-air  exisiem-e,  icuaidless  dt  essen- 
tial meteorologic  conditions,  represents  the  sole  important  desideratum. 
An  inquiry  in.stituted  for  the  purpose  of  determining  what  foundation, 


66S  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

if  any,  exists  Ici  the  iiiciilcatuin  disucli  helief.  discloses  an  utter  disregard 
for  scientific  pniM  ipli-  ^r  i-iaMi-lKMl  cluneal  facts.  The  position  of 
climate  as  a  tactnr  ni  cxccrdiu;:  \  aliio  ill  ihi'  treatment  of  consumption 
can  never  be  assailed  by  thr  hkic  (■x|iic.-si..ii  uf  opinion.  No  dictum 
is  worthy  of  general  acce]itaiirc  n  iii-|iircd  \<y  nther  than  a  disinterested 
desire  for  truth.  The  only  laiinnai  ^a^l-  cither  for  faith  or  for  disbelief 
in  the  efficacy  of  climatf  inu-t  cxi  i  in  i  l.r  lundamental  logic  of  clinical 
facts  supported  by  lunad  piactiral  (irduiii.iiis  founded  upon  a  study  of 
atmospheric  phenoiiicna  and  inctcnrdldi  ir  laws.  A  renunciation  of 
climatic  tiullis  is  jusiilicd  only  by  the  submission  of  demonstrable  data 
sufficient  ti'  ci.n-titnic  iirclntabie  negative  evidence.  In  view  of  the 
accunuilatinii'  ti'stiniony  cdncerning  the  physiologic  effect  of  climate, 
and  the  mass  of  clinical  e^•idcnce  alread>-  adduced  in  Mibstantiation  of 
such  an  influence,  it  almost  appears  that  the  liuiilen  >  i  pnidf  rests  with 
any  who  may  have  indulged  in  more  or  le-s  \  imIcih  icpudiation. 

Thei-e  are  Init  tim  uriiinmids  wnrtliy  ci|  ci.n.M.leialion,  to  be  advanced 
by  the  ojijiofii  Ills  ni  climate:  liist,  the  kimwledne  that  Some  cases  of 
tuberciilnsis  ultimately  lecnNcr  in  any  liic(ilit;i.  as  the  result  of  a  proper 
outdoor  regime;  secondly,  that  simie  fail  to  secure  good  results  although 
subjected  to  a  prondunced  change  of  cfimatic  conditions. 

The  first  propo.silinii  relates  to  the  occasional  arrest  of  a  disease 
formerly  suppnsed  in  \<c  alncst  entirely  hopeless.  Considerable  opti- 
mism i>  naiinail\  In  I je  ex| lected  from  the  recognition  of  such  beneficent 
possil.iilitie<  fur  eailx  ca.-es.  ilinmgh  the  injhteiicc  of  a  properly  conducted 
method  of  livi)iy.  (.'iMi.-umptinn,  Imwexei-.  irrespecti\t'  nf  climate,  maj' 
become  arrested  in  smne  instances,  ihsjiitt  inili'i'iu  nir  .surroundings, 
undue  exposure,  ins.ifilrii  nl  fmiil  <ir  cloth i mi.  unit  jiiunirinl  distress,  an 
important  factor  in  the  e\o|iition  of  complete  arrest  being  the  measure 
of  ivln  11  lit  iiiiliri'hiiil  r,  sl.siiiiicc.  The  sequence  of  thought  is  plain 
to  the  etf(^ct  tliat.  excn  in  nnta\-oraljle  locations,  a  certain  proportion  of 
earl}-  cases  nuist  inevitably  i;et  well  upon  simple  change  of  environment 
and  mode  of  living.  This  doc-,  not  necessaiily  imply  that  such  change 
alone  is  all-sufficient  for  general  application,  but  indicates  merely  that 
in  some  incipient  ca^i^s  imponani  niodilications  of  previous  conditions 
and  surround nms  max  t  urn  i  he  1  cilaiice  i  eiiiporaril\-  m  favor  of  recovery. 
In  many  iii.-iance-  i  he  predonnnani  faclor  con>ists  of  the  personal 
supervision  oi'  !iv-ir!nc  deiaiU,  i  he  impon  aiicr  of  which  is  not  open  to 
dispute.  The  oxerw  helniiuLi  e\  idiMice  ihai  con.~iuni)tion  is  sometimes 
arrested  in  un-mtalile  reuions  i~  far  from  predicating  the  assumption 
that  climate  is  of  no  value  for  the  enormous  remaining  number  of 
pulmonary  invalids.  As  well  might  it  be  inferred  that  because  some 
patients  recover  from  various  diseases  without  medication,  judicious 
recourse  to  drugs  is  in  all  instances  of  nn  avail.  Carefulh'  directed 
mental  suggestion  has  been  found  of  therapeutic  efficacy  among  a  class 
of  nervous  invalids,  but  the  recognition  of  this  scientific  principle 
affords  no  jiistiHcation  for  the  de\elo]iment  of  a  system  of  religious 
belief  ,-uitaMe  for  i  he  cure  of  l.oilily  ills.  In  other  words,  the  recognition 
of  the  po~MMc  henefii  accruint;  to  individuals  having  complaints  does 
not  waiiaiit  ihc  :i"iiiiiplion  that  this  cult  is  applicable  to  f/lVase.  The 
analoL;\  -ui;ui-icd  heiween  apjiarent  supernatural  healing  and  the  utter 
repudiation  of  clim.iiic  intluenco  for  consiiinpti\-es  is  more  real  than 
imaginary,  the  principle  iuxdked  in  either  instance  being  the  acceptance 
of  a  demonstrable  trutli,  but  an  utter  misinterpretation  of  its  signifi- 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       669 

cance  and  applicability.  The  fact  that  imaliils  (icca^^idiially  recover 
from  incipient  tuberculofsis  wiilmiit  i-limalic  cliaii.iic,  is  no  mure  to  be 
considered  as  an  argument  against  the  wisdum  of  its  intelligent  applica- 
tion in  individual  cases,  than  is  the  recovery  without  operation  of  a 
given  patient  with  appendicitis  to  be  considered  a  reflection  upon  the 
general  expeiliencv  of  surgical  interference. 

The  smind  r'„vs„l<  r<ili<w  leading  to  pronun.-iamentos  icgai'ding 
the  non-efficacy  oi'  rlimaie,  relates  to  the  not  i/ifnyiKnl /(uliin  lo  secure 
arrest  in  fax'oi'alile  regions.  That  griev<iusly  unfori  iinaie  conditions 
bestrew  the  path  of  mau>-  \-ictims  of  tub-i'ciijosi-.  in    lieallli   ivsoits  no 

inquire  as  to  the  und.'i'iymg  causes  of  I  he  ilj-li-e—  obsei'N'ed  in  I'limates 
popularly  believetl  to  possess  some  (hreci  inlhieiice  upon  pulmonary 
invalids.  The  fact  is  at  once  de\ilo|ie<|  ihai  ihere  aic  sent  annually 
to  health  resorts  a  consitlerable  numliei'  ol  phihi-ical  patients,  wdio 
should  have  been  jiermitted  to  end  ihei:'  da\  s  al  home.  It  i>  also  afipar- 
ent  to  the  experienced  ol)sei\ cr,  thai  Iml  lillle  judgment  is  displayed 
in  many  instances  in  the  silrdion  of  <i  liicalihi  aiipropi'iate  foi-  the 
individual  needs  of  those  \\ho,  u|  tui  the  merit-  of  their  condition, 
recjuire  climatic  change.  As  will  be  shown  pi'e>entl\,  the  ut  mo-i  dis- 
crimination and  acumen  must  be  exhibited  in  each  ca-r  in  determining 
the  cardinal  prin.aples  upon  which  t  he  ch.iice  ol' chmai  e  Mionld  lie  l.ased. 

There  is  no  mu-I,.  chmate  applical  .I.'  lo  all  ca-c-  ,,|  coi,Mim|  ,t  ion. 
The  peculiarities  of  teni|.eranient .  the  e\(a'-\  ar\  mg  coml , mat  ions  of 
physical  signs,  the  ass.iciated  di,-t  urbaiice  of  (Mrculatioii,  digestion,  and 
elimination,  and  the  financial  status  furni.^h  a  combination  that  must 
be  adjudgeil  ///  nlnhon  lo  tin  !.:n,>in,  /ili  ,/si,ili„/ir  ,  iJVrl  of  lli,  nirious 
cUinat'rs  oikI  Ihr  llu  ni  p,  iitir  orlooi  lo  h,  (hsnril.  i  ii 'main' caMS  failure 
to  attain  the  best  results  from  climatic  change  is  uiidoiibte'illy  occasioned 

by  lack  of   familiarity   with   the   pred.iininating  at spheric   attributes 

in  ditferent  localities,  and  their  ]il]\sio|ogic  effect  upon  an  organism 
modilied  b\-  diM'.a.^e  and  b\-  |ire\iou>  eiiMroument. 

Although  the  iiii>iiilaliility  of  a  part  iiailar  climate  is  often  a  potent 
cause  for  ultimate  disaster,  this  leature  prr  s,  does  not  fully  explain  the 
deplorable  results  loived  upon  the  ol  .ser\ation  of  ph\siciaiis  m  health 
resorts.  It  should  be  borne  in  mind  that,  in  a  wist  majority  of  iiist  .-nices, 
failure  takes  place  not  because  of  climatic  change,  but  /(/  s/oir  of  it, 
the  essential  factor  in  determining  the  limil  issue  being  the  complete 
non-conformity  to  hygienic  principles  of  li\ing.  An  astonishingly 
laroc  number  of  pati.'aits  aiv  led  to  a\ail  fhemsehcs  of  the  siip|io,sed 
advaiitag.'S  of  an  injudiciously  sel.vted  clim.ate,  without  the  sloihtcst 
(ippnroihon    of  Ihr    nohirr    atn'l    r.rlnil    of  lloir    p,  rsouol    ,>  s poii^ohil liics. 

Some  arc  entindy  iiniiist  riicli'd  or,  al  best,  are  without  that  degree  of 
medical  super\  ision  which  insures  compliance  with  directions.  Others, 
as  the  result  of  irrational  ad\ice,  are  impelled  to  indulge  in  various 
excesses  suliicieiit  to  desiro\-  e\-eii  .a  renioli'  possibiht}"  of  recovery. 
A  very  coii,,ider:ible  mimlier  of  innor.ant.  fri\-o|ous.  and  impatient 
Consumpti\-es  Hoat  like  \-erit,aMc  llot-,-im  and  jets.am  iipmt  Ihrir  oum 
initiatiir,  drifting  aimles-l\  from  one  resort  to  aiiothei-.  Such  patients 
are,  as  a  rule,  but  slightly  aineiial)le  to  jiidiiaous  goxcrning  inlhiences, 
and  come  uniler  medical  obseixation  onl\-  at  times  of  acaite  manifesta- 
tions. 

In  former  years  climatic  change  was  often  advised  regardless  of  the 


670  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

constitutional  condition  of  the  patient,  or  of  the  extent  and  activity  of 
the  disease.  Localities  possessing  radically  different  climatic  con- 
ditions were  indiscriminately  recommended  to  phthisical  patients. 
Invahds  chancing  to  consult  a  number  of  physicians  before  directing 
their  steps  toward  a  distant  clime,  might  have  been  ordered,  according 
to  the  choice  of  their  advisers,  to  such  widely  differing  regions  as 
Colorado  and  the  Bermudas,  Florida  and  the  Adirondacks,  New  Mexico 
and  portions  of  North  and  South  Carolina,  California  and  Arizona. 
It  is  obvious  that,  if  the  climatic  conditions  peculiar  to  one  of  these 
localities  are  adapted  to  special  individual  needs,  some  of  the  other 
regions  must  be  less  favorable  in  their  influence,  if  not  distinctly  preju- 
dicial. 

The  errors  of  judgment,  which  ha\-e  been  displayed  in  the  selection 
of  climate,  have  served  onlj'  to  acccentuate  the  unfortunate  results  of 
deferred  diagnosis.  Temporizing  delay  on  the  part  of  the  jjhysician 
after  the  nature  of  the  condition  has  become  estabhshed  is  explanatory, 
in  large  measure,  of  the  indifferent  success  attained  after  removal  to 
favorable  climates.  It  is  also  resjjonsible  to  a  considerable  extent  for 
the  reflections  unjusth'  cast  upon  the  utility  of  climatic  change. 

Ill-considered  advice  with  reference  to  the  policy  of  therapeutic 
management  many  times  has  been  imparted  by  medical  attendants, 
at  home  and  in  health  resorts.  Until  recent  years  it  has  been  no  uncom- 
mon experience  in  favorable  climates  to  observe  patients  who  ha\e  been 
admonished  to  avoid  doctors,  to  climla  mountains,  to  ride  horseback, 
and  to  drink  whisky.  Some  physicians,  in  sending  their  patients  away 
from  home,  have  seen  fit  to  issue  instructions  as  to  the  entire  future 
conduct  of  the  patient.  Many  invalids  have  been  told  to  beware  of 
medical  advice,  or  at  most  to  secure  an  opinion  as  to  results  obtained 
only  upon  the  lapse  of  several  months  after  arrival.  JIany  of  these, 
as  a  direct  result  of  the  injudicious  counsel  of  their  home  advisers  with 
reference  to  exercise,  work,  or  manner  of  living,  are  compelled  to  seek 
medical  aid  much  sooner  than  anticipated.  The  reputation  of  climate 
has  alsii  bopii  maile  tn  siiffpv  for  numerous  errors  of  professional  judg- 
ment ciiiiiiiiitrc^l  li\'  ic-i^lciit  !'!i\ -iciaiis.  It  is  idle  to  comment  upon 
the  itiiii'iaiit,  iinii-ct hical  till,  III  -'Miici lines  assuming  to  exercise  juris- 
dictiiui  "\cr  the  |ihysical  destinies  ut  tlie  consumptive  in  health  resorts. 
It  is  api'aiiMiT  that  medical  counsel  received  from  these  sources  has  too 
often  licrii  'Itlivcied  without  the  incumbrance  of  knowledge  or  the 
handicap  uf  conscience. 

In  but  comparatively  recent  years,  has  the  necessity  of  rational 
living  been  insisted  upon  by  medical  ob-servers.  In  any  discussion 
bearing  upon  the  relative  merits  of  climatotherapy  and  the  so-called 
home  treatment,  due  cognizance  should  be  taken  of  the  fact,  that  the 
doctrine  of  hygienic  living  was  early  emphasized  l)y  meilical  workers 
in  favnralijp  climates.  Largely  through  their  efforts  the  profession 
has  l)cfii  Uiu-hr  the  importanceof  rational  living, and  advised  concerning 
the  rule  111  rliiiiatc  as  a  valuable  adjuvant  to  other  measures  of  thera- 
peutic nuuia.iicmcnt.  During  the  past  decade  an  unceasing  endeavor 
has  been  made  by  observers  in  healthful  localities,  to  inculcate  among 
general  practitioners  a  degree  of  familiarity  with  the  practical  side  of 
climatotherapy.  Numerous  appeals  have  been  made  for  the  exercise 
of  a  wise  discrimination  concerning  the  character  of  invalids  permitted 
to  journey  to  a  distant  land. 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS      671 

The  non-recognition,  in  former  years,  of  the  importance  attaching  to 
hygienic  details,  is  being  replaced  by  a  tendency  to  exalt  the  value  of 
a  suitable  regime  far  above  the  influence  of  climate.  An  unfortunate 
phase  of  American  life  is  the  tentlency  to  go  to  extremes.  Once 
awakened  to  the  importance  of  strict  hygienic  methods,  the  medical 
profession  has  been  prone  to  accejjt  this  feature  as  the  chief  therapeutic 
indication.  No  greater  menace  to  the  welfare  of  the  consumptive  now 
exists  than  the  further  development  of  the  delusion  regarding  the  futility 
of  climatic  change.  It  is  not  surprising,  h()w(>vor.  in  view  of  the  incon- 
testable merits  of  pro;  )ril\-  rrmiUitcd  iiii'tlinils  oi'  IJMiig  in  any  locality, 
and  the  many  causes  Uh-  lailuic  in  liculili  icsciits.  thut  an  inclination  is 
displayed  to  regard  fresh  air.  witliDUt  reference  to  modifying  conditions, 
as  the  sole  atmospheric  desideratum.  The  fallacy  of  such  reasoning  is 
apparent  upon  consideration  o(  the  affirmative  aspects  of  climatic 
influence. 

Affirmative  Evidence. — The  evitlence  upon  which  there  may  be 
returned  a  final  verdict  as  to  the  l)eneficent  role  of  climate  is  found: 
(1)  In  the  known  physiologic  effect  ])roduced  by  various  climatic  attri- 
butes, either  separate! \-  nr  jciimly:  ('_''  in  tlic  unimpeachable  testimony 
presented  as  a  result  ol  ini]KU  tiul  clinical  (il>M'i\a,tion. 

Preliminanj  to  any  re\ic\\  nl'  ihc  dmionst  i-able  influence  of  atmos- 
pheric conditions  upon  the  luima.n  oi-aiiisin,  it  is  well  to  define  what 
is  meant  by  climate,  and  to  cnuincratc  its  essential  factors.  Reference 
to  the  views  entertained  li>-  luiniciuus  nicicdiDlogists  suggests  the  follow- 
ing definition  of  climate,  /,  c  the  cliara,cteii,-t  ic  \ve,a,tlier  t<ita.lit\-  (if  a 
region,  re.sulting  from  the  c(nnlinied  elTecl  of  all  ilie  meteorolo-ii-  phe- 
nomena which  influence  \-egetalile  piiMliicI  ion  and  animal  deNclopnient. 
This  definition  suiiuests  the  ininieilia,tc>  inlluencc  of  the  stun  of  utnio.s- 
pheric  con.litions  upon  the  vitality,  comfort,  and  nitellectual  <levelop- 
ment  of  indi\iduals.  In  tiiitli.  no  otlief  siiiule  f;ictor  in  the  environ- 
ment of  a  people  is  endowed  with  power  to  influence  their  health, 
material  welfare,  and  fntuie  destinies  to  sucli  an  extent  as  climate.  Its 
molding  effect  upon  character  and  disposition  has  been  recognized  for 
ages,  notwithstanding  the  fact  tlnit  essenti.il  (Hlferences  in  this  respect 
have  been  attriliutable  in  part  to  nation.il  (  li.u.icteiistics.  It  cannot 
be  denied  that  the  jihysical  condition  of  the  at  mo- plieie,  with  its  direct 
effect  upon  the  flora  and  taiina  <if  any  re'^ion.  e,-IaMi-lies  to  some  extent 
the  nature  of  indiist  rial  piiistuts,  deteiinine^  to  a  ileui-ee  the  character 
of  physical  and  intellectual  dexclopnient ,  and  iirofoiuidly  modifies  racial 
peculiarities. 

Convincing  testimony  as  to  the  unfailing  influence  of  climate  in 
stamping  characteristic  differences  upon  the  same  people  amid  diverse 
atmospheric  conditions,  is  found  in  a  comparison  of  the  predomi- 
nating qualities  exhibited  in  remote  localities  by  a  single  race. 
Differences  of  character  displayed  by  the  noithern  and  southern  inhabi- 
tants of  Germany,  Russia,  S])ain,  i-'r.'un-e,  lta.l\-,  and  (Iiin.a,  to  which 
Huggard  has  called  attention,  are  par.dleleil  li\-  the  exhilnl  ion  of  similar 
modifications  of  development  and  disjiosition  hetweeii  the  northern 
and  southern  people  of  the  United  States. 

History  is  replete  with  instances  of  unsuccessful  effort  in  the  way 
of  colonization  in  strange  climates,  although  the  initial  conquest  was 
irresistible,  the  subsequent  occupation  unopposed,  and  the  reinforce- 
ment of  population  continuous.     Failure  of  racial  acclimatization,  even 


672  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

after  the  lapse  of  seM-nil  generations  of  endeavor,  has  resulted  to  a  great 
extent,  from  inabilit>-  of  nations  to  adapt  themselves  to  weather  con- 
ditions, markedly  dissimilar  to  those  to  which  they  have  been  accus- 
tomed. 

The  combined  atmospheric  phenomena  commonly  described  as 
weather,  bear  reference  chiefly  to  variations  of  heat  and  cold,  moisture 
and  dryness,  the  direction  and  velocity  of  the  wiiui.  atin(is]jlieiic  pres- 
sure, and  the  amount  of  sunshine.  These  attribute-  di  ilmiate,  which 
are  of  especial  importance  to  students  of  phthisiotliciapy  and  clima- 
tologj^  are  the  result  of  such  causative  factors  as  latitude  and  altitude, 
the  character  of  the  soil,  rainfall,  extent  of  frost,  and  the  distribution 
of  air-currents.  From  the  standpoint  of  the  physician,  it  is  unnecessary 
to  dwell  even  briefly  upon  the  uii(lcil>iiiti  influences  responsible  for  the 
creation  of  the  various  atnKJ-niiciir  ((nulitions.  Interest  centers  more 
particularly  upon  the  .several  tnustitucnt  attrilnites  of  climate,  and  their 
effect  upon  ]ih\-i(iloL;ii-  fumtioiis  of  the  liody.  Such  inquiry  is  more 
pertinent  to  tlr-  |imi )n<es  n\  cliniatotherapy  than  is  a  detailed  consider- 
ation of  the  nia.n>-  luiiclanicntal  agencies  involved  in  the  production  of 
climate. 

Among  the  climatic  attributes  capable  of  exerting  a  profound  influ- 
ence upon  the  animal  organism,  a  place  of  some  importance  by  popular 
accord  has  been  assigned  to  the  chemic  and  bactcriologic  'purity  of  the 
air.  Insistence  upon  chemic  purity  of  the  atmosphere  as  a  sine  qua  non 
for  the  health  of  individuals,  presupposes  the  idea  that  the  actual  com- 
position of  the  air  i<  siibjcit  ic  cniisidcralile  variation  in  different  loca- 
tions. This  notion  as  in  (liiicicii'  r-  in  the  relative  amount  of  oxj'gen, 
nitrogen,  carbonic  acid  and  mluT  ingredients  has  been  found  to  be 
erroneous,  save  in  rclatKni  tn  nnijnnil  .-./) 
sion  of  gases  is  preveiitiil  and  ilic  iiiHucn 
By  virtue  of  the  latter  aucUMc-  tin'  c/n  mi, 

is   subject    to    almost     Inti pi^  ■n-, ,<!:!,     r.im 

strated  in  the  immediaic  \  ninii  y  n\  hiiLi- 
and  in  close  ]»n)\iiiiny  \n  dciiM.  tuiv-t-^ 
lous  di>ti'ict-  till'  air  i-  "ll-ii  |i(.lliitc(i  I  .\-  , 
In  sucli  LiralHic-  a  i.nl:nl  la,rl,,r  iin-  all 
emailatiiiii  dl'  -iniil..i'  iVdin  larui'  rhiniiii 
althou-ll  piVM-|!l    I(,a,  l(--r\lcll1    ill  tlu-l 

may  iminvmiaic  the  air  m  tiic  (-(111111 1>-  as  well  as  (iT  the  city.  While  the 
deleteridiis  crirri  di  clicinic  ai  iiidsiiliciic  impurities  in  ill-ventilated 
apartment-,  ami  nf  ilust  contamination  or  bacteriolo.cic  pollution  in 
densely  iHipulaied  districts  is  too  apparent  for  further  comment,  the 
elementary  ((imposition  of  the  air  is  devoid  of  practical  significance  with 
reference  to  a  consideration  of  climate. 

PHYSIOLOGIC  CONSIDERATIONS 
The  utmost  interest  attaches  to  a  conception  of  the  manner  in 
which  the  system  is  affected  by  the  various  combinations  of  atmos- 
pheric conditions.  In  reviewing  the  physiologic  action  of  the  several 
climatic  attributes  upon  the  organism,  brief  mention  will  be  made  of 
the  more  important  conclusions,  which  have  been  recorded  as  the  result 
of  much  systematic  study  by  scientific  investigators.  No  deductions 
will  be  presented  which  have  not  stood  the  apparent  test  of  patient 
research  and  pitiless  criticism. 


,lu-r<.  th 
AimI  is  a 
n.^  it  ion  d 

e  complete  diffu- 
.Itdgetlier  absent. 
i  the  atmosjiliere 

This   li 

as   been    demon- 

, uiKinil 

le  !U  I'^ili 
articl(v-  1 

ic  r elated  iilains, 
I'dihddd  of  popu- 
.1  nidiianic  dust. 
amiiiation  is  the 

V.aeterK 
il.-liar-cl 

ilduic  impurities, 
ly  settle(_l  regions. 

CLIMATE  IN  THE  TREATMENT  OF  PULMONARY  TUBERCULOSIS   673 

It  may  be  stated  as  a  preliminary  postulate  that  the  chief  beneficent 
action  of  climate  consists  of  a  profound  influence  upon  tissue  change,  which 
transcends  in  importance  any  primary  effect  upon  the  diseased  organs 
of  respiration.  The  potentialities  of  climate  relate  not  so  much  to  the 
existence  of  an  atmosphere  supposed  to  be  enaowiMl,  on  uccount  of  its 
freshness  and  purity,  with  peculiar  virtues  for  the  puipotic.'i  of  inspiration, 
but  rather  to  its  presence  as  a  surrounding  medium,  possessing  qualities 
capable  of  exerting  a  decided  influence  upon  metabolism.  Through 
the  instrumentality  of  a  continuous  but  irregular  air-bath  a  reaction 
is  often  established  sufficient  to  modify  functional  equilibrium.  This 
influence  upon  the  animal  functions,  which  represents  the  response  of 
the  individual  to  climatic  change,  determines  the  measure  of  the  result- 
ing effect  upon  nutrition,  and  hence  is,  in  reality,  the  vital  factor  in  the 
physiologic  problem.  Climate  then  should  be  studied  with  reference 
to  changes  induced  in  the  stability  of  functional  processes.  According 
as  the  animal  functions  are  stimulated  or  impaired,  metabolism  is  influ- 
enced for  the  better  or  worse  respectivel}^ 

An  important  factor  in  determining  the  character  and  extent  of 
alteration  of  fimction  is  the  demand  for  heat-production,  which  fluctu- 
ates proportionately  with  the  amount  of  heat-abstraction.  In  turn 
the  degree  of  heat-abstraction  varies  in  accordance  with  essential  differ- 
ences in  climatic  conditions.  Hence  a  certain  relation  is  establisheil 
between  the  heat-abstracting  powers  of  a  climate,  and  the  attainment 
of  maximum  nutrition,  the  sequence  of  action  being  the  effect  of  certain 
climatic  attributes  in  abstracting  the  heat  of  the  body,  the  consequent 
demand  for  greater  production,  the  stimulation  of  the  various  physio- 
logic functions,  with  increased  metabolism  and  improved  nutrition. 
Evolutionary  changes  of  such  satisfying  nature  are,  of  course,  contingent 
upon  the  ability  of  the  individual  to  respond  to  the  unusual  demands 
for  heat-production. 

The  practical  effect  of  climatic  change  varies  widely  according  to  the 
vigor  of  the  oxicUzing  process,  this  factor  in  a  decision  as  to  the  availa- 
bility of  certain  climates  being  even  of  greater  importance  than  the 
extent  or  character  of  the  tuberculous  infection.  The  personal  equation 
thus  becomes  an  important  consideration  in  ascertaining  the  value  of 
the  physiologic  change  in  different  people  exposed  to  the  same  climatic 
conditions.  In  general,  the  influence  of  climate  upon  nutrition  is 
largely  contingent  upon  the  degree  of  its  heat-abstracting  capabilities, 
which  feature  is  defined  by  Huggard,  in  his  admirable  treatise  upon 
the  physiology  of  climate,  to  be  the  one  fundamental  principle  of  clima- 
totherapy.  In  view  of  the  fact  that  the  possibilities  of  heat-abstraction 
in  any  climate  are  dependent  upon  temperature  in  connection  with  the 
modifying  influence  of  humidity  and  wind  movement,  it  is  well  to  consider 
these  factors  in  common. 

Despite  extreme  variation  in  the  physical  condition  of  the  surround- 
ing air,  the  temperature  of  the  body  in  health  remains  practically  con- 
stant. The  removal  of  heat  from  the  organism  is  subject  to  great 
fluctuation  Ijy  virtue  of  diurnal,  seasonal,  and  climatic  changes,  influenc- 
ing essentially  the  manner  as  well  as  the  degree  of  its  abstraction.  It 
follows  that  a  corresponding  variation  must  exist  at  different  times  in 
the  working  efficiency  of  the  heat-producing  apparatus.  The  non-vary- 
ing temperature  of  the  body  is  manifestly  not  the  result  alone  of  a  fixed 
amount  either  of  heat-production  or  of  heat-dissipation,  but  rather 


674  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

the  balance  obtained  from  a  perjcctly  adjusted  relation  of  respoixse  to 
demand.  Through  automatic  control  of  the  mechanism  involved  in 
heat-production,  the  supply  is  regulatetl  precisely  by  the  expenditure. 
Thus  the  processes  of  oxidation  chiefly  responsible  for  the  development 
of  animal  heat  are  directly  modified  by  external  conditions  affecting 
heat-abstraction.  With  increased  removal  of  heat  from  the  body,  the 
peripheral  contraction  of  blood-vessels  is  accompanied  by  hyperemia 
of  internal  organs,  with  greater  consequent  activity  of  the  oxidizing 
processes  engaged  in  heat-production.  Conversely,  with  diminished  loss 
of  heat,  liy  reason  of  peculiar  atmospheric  conditions,  a  compensatory 
effort  is  made  to  favor  its  removal  by  an  increased  functional  activity 
of  the  skin,  with  engorgement  of  the  surface  vessels  and  corresponding 
depletion  of  the  circulation  in  the  alidominal  and  other  internal  organs. 
With  lessened  heat-dissipation  oxidation  is  retarded  and  functional 
activity  diminished.  If  the  removal  of  heat  is  facilitated,  the  stimu- 
lating effect  upon  digestion  and  a.ssimilation  is  pronounced  in  accordance 
with  the  general  law  of  response  and  demand.  Waiving  for  the  time 
being  the  question  of  personal  equation,  it  may  be  stated  broatUj'  that 
the  increased  expenditure  of  heat  is  followed  by  renewal  of  supply, 
which  is  attended  by  such  functional  activity  as  to  entail  promotion 
of  metabolism  and  improvement  of  nutrition.  In  proportion  to  the 
degree  of  heat-dissipation  there  is  also  exerted  within  certain  limits  for 
different  individuals,  an  influence  upon  the  tone  of  the  general  muscular 
and  nervous  systems.  Save  in  exceptional  extremes,  the  stimulation  or 
impairment  of  energy  varies  respectively  with  the  increase  or  diminution 
of  heat-dissipation. 

The  removal  of  heat  is  not  altogether  commensurate  with  the  tem- 
perature of  the  surrounding  air.  An  important  modifying  influence  is 
found  in  the  amount  of  contained  moisture.  With  respect  to  the  degree 
of  relative  humidity,  striking  differences  are  recognized  between  the 
physical  and  sensible  temperatures  of  an  atmosphere,  which  involve 
corresponding  variations  in  the  extent  of  heat-dissipation.  In  moist 
regions  common  experience  attests  the  raw.  chilling  effect  of  moderately 
cold  weather  and  the  relaxing,  enervating  influence  of  heat.  Upon  the 
other  hand,  in  dry  climates,  the  sensible  appreciation  of  winter  cold  or 
summer  heat  is  minimized  to  a  perceptible  degree.  In  cold  dry  weather 
the  heat  is  removed  chiefly  by  radiation,  which  is  greatly  reinforced  by 
conduction,  if  the  element  of  moisture  is  substituted  for  that  of  dryness. 
In  warm  dry  regions  the  heat  is  dissipated  by  evaporation  of  the  per- 
.spiration,  and  to  some  extent  b}'  radiation,  both  of  which  agencies  are 
seriously  retarded  in  their  action  by  the  presence  of  moisture  in  the  air. 
Thus  a  humid  atmosphere,  on  account  of  its  relatively  good  conductive 
qualities,  becomes  unduly  effective  in  the  removal  of  heat  in  cold 
weather,  and  interferes  with  evaporation  during  the  hot  season,  inten- 
sifying the  uncomfortable  effect  of  both  extremes. 

The  disadvantage  of  moisture  is  not  confined  to  its  above-mentioned 
unfavorable  influence  during  excessive  heat  or  cold.  It  is  found,  even  in 
the  presence  of  moderate  temperatures,  that  the  loss  of  heat  by  means 
of  conduction  is  disproportionate  to  the  actual  needs  of  the  organism. 
Under  such  conditions  the  heat-abstraction  is  often  unrestricted  by  the 
protecting  action  of  peripheral  contraction,  and  proceeds  benond  the  capac- 
ity of  the  heat-producing  apparatus  for  immediate  supply.  The  chilling 
effect  is  further  accentuated  by  the  wearing  of  apparel  which,  upon  satu- 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       675 

ration  with  moisture,  possesses  excellent  powers  of  conduction.  Cotton 
garments,  which  are  good  conductors  of  heat,  even  in  the  dry  state,  derive 
increased  conductivity  when  moist.  In  the  event  that  surface  con- 
striction be  sufficiently  prompt  to  produce  internal  hyperemia  and  stimu- 
late the  oxidizing  processes  to  greater  activity  in  the  production  of  heat, 
the  conduction  becomes  ineffective  in  reducing  the  surplus,  while  radi- 
ation and  evaporation  are  inoperative  by  reason  of  the  moisture.  In 
addition  to  the  resulting  physical  discomfort  and  sense  of  inertia,  the 
functional  activities  are  again  impaired,  oxidation  diminished,  and 
derangements  of  dige.stidii  rcndcnMl  pi'dhaJdc,  tductlici-  with  rcdnclion 
of  nutrition.  Huggurd  has  called  ul  tcnl  imi  xcvy  clcail\  In  the  mi|i<iitaiit 
difference  between  heat -abstract  ion  m  dry  and  insist  loralities,  the  dis- 
tinguishing characteristic  in  dry  regions,  being  the  renio\al  of  heat  by 
radiation  and  evaporation  in  rather  strict  accordance  with  the  peculiar 
necessities  imposed  upon  the  organism  by  external  conditions.  In  the 
presence  of  moisture,  howe\'er,  e\a]i<iiation  and  radiation  are  hindered 
and  conduction  either  Ijeconies  insliuiiieiital  in  an  undue  depletion  of 
the  heat  store,  or  is  inadequate  to  remove  an  overalnindant  supply. 
Its  action,  therefore,  would  seem  distiin-tly  embarrassing  to  the  normal 
physiologic  relation  between  response  ami  deiiiaiid. 

Another  important  modifying  feature  in  the  alistraction  of  heat  is 
the  presence  of  wind,  through  which  agency  louvectioii  becomes  (i])er- 
ative.  By  means  of  this  influence  the  action  of  both  cold  and  moisture 
is  greatly  exaggerated.  The  general  character  of  winds  is  dependent 
upon  the  influence  of  fundamental  natural  factors.  The  degree  of  heat 
removal  and  the  other  physiologic  effects  upon  the  organism  are,  of 
course,  dependent  upon  the  chfferent  ciualities  of  the  wind.  Chilling, 
enervating,  or  other  disagreeable  effects  accrue  in  different  places  and  at 
varying  times,  according  to  cUrection,  force,  and  duration,  in  association 
with  temperature,  dryness,  and  the  amount  of  dust  held  in  suspension. 
The  importance  of  wind  in  this  connection  relates  chiefly  to  its  action 
under  certain  condition  ■.  in  niodil'ving  the  influence  of  temperature  and 
dryness  in  the  removal  of  body-heat.  It  goes  without  saying  that  Init 
slight  movement  of  the  air  is  necessary  to  intensify  the  effect  of  cold  in 
winter,  or  of  moisture  during  warmer  seasons.  Even  in  the  presence  of 
atmospheric  dryness,  heat-chssipation  is  markedly  accentuated  by  wind, 
radiation  becoming  more  active  in  cold  weather  and  evaporation  in 
summer. 

Evaporation  is  also  increased  by  the  diminution  of  atmospheric 
pressure  incident  to  altitude.  It  usually  happens  that  extreme  dry- 
ness occurs  in  combination  with  altitude  and  wind  velocity.  Under 
such  conditions  in  mountainous  districts,  heat -abstraction  is  facilitated 
by  the  action  of  the  colder  temperature  and  the  increased  dryness 
peculiar  to  the  locality,  as  well  as  through  the  influence  of  lessened 
atmospheric  pressure  and  local  air-currents  of  \ariable  intensity.  The 
distinguishing  characteristics  of  such  regions  a,re  coolness,  dryness, 
rarefaction  of  air,  with  its  coni]ilicated  jihysiojoaic  elTect  upon  the 
organism,  prevalent  winds,  and  niriiilnlitij  of  teini)eratui'e.  Equability 
of  temperature,  which  is  erroneously  regarded  by  some  as  a  concomitant 
of  altitude  and  dryness,  in  reality  is  unavoidably  associated  with  the 
humid  atmosphere  of  the  lowlands. 

From  the  preceding  considerations  it  is  seen  that  equability  of  tem- 
perature per  se  does  not  necessarily  constitute  a  desirable  feature  of  any 


676  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

climate,  with  reference  to  its  intrinsic  demands  upon  the  body  for  heat- 
production.  Its  obvious  disadvantage  in  this  respect  is  greatly  aug- 
mented bj'  its  close,  unavoidable  relationship  with  atmospheric  humidity. 
As  has  been  pointed  out  by  Huggard,  equability  of  temperature  in  asso- 
ciation with  moisture  does  not  produce  regularity  of  heat  demands  upon 
the  physiologic  apparatus  for  heat-production,  but.  upon  the  contrary, 
does  effect  such  variabilitii  of  expenditure,  out  of  proportion  to  the  needs 
of  the  body,  as  to  embarrass  seriously  the  mechanism  for  supplj-.  Upon 
the  other  hand,  through  the  influence  of  dryness,  variability  of  temper- 
ature is  capable  of  pi-oducing  in  general  only  such  abstraction  of  heat 
by  means  of  rachation  and  evaporation,  as  will  result  in  an  adaptation  of 
the  organism  to  these  external  factors.  It  is,  therefore,  important  to 
distinguish  between  the  equabilitu  of  temperature  in  a  climate  with 
variability  of  heat-dissipation,  and  an  adaptabilitij  of  the  body  to  irregii- 
lariti/  of  heat  demands  in  a  variable  climate. 

The  vital  consideration  in  determining  the  idtimate  effect  upon 
metabolism  and  nutrition,  is  the  response  of  the  organism  to  the  influence 
of  the  external  factors  engaged  in  the  remo\-al  of  heat.  The  degree 
and  chai-acter  of  the  response  are  subject  to  considerable  variation  by 
reason  of  e.xisting  conditions  peculiar  to  the  individual.  Thus,  identical 
attributes  may  induce  extremely  chverse  reactions  in  chfferent  people. 
This  feature,  therefore,  constitutes  a  factor  of  great  importance  in  de- 
fining the  general  efTect  of  climate  upon  individuals.  Thus,  the  stim- 
ulating effect  resulting  from  the  removal  of  body-heat  is  contingent 
upon  the  capabilities  of  the  individual  to  respond  to  the  increased 
demand.  Change  of  climate  may  be  beneficial  or  injurious  not  solely 
in  accordance  with  the  nature  of  strange  external  contlitions,  but  as  well 
with  the  degree  of  adaptation  of  the  individual  to  the  new  climatic 
environment.  It  is  important,  therefore,  to  adjudge  the  value  of  climate 
from  its  relation  to  the  invalid  in  question,  rather  than  from  an  abstract 
consideration  of  its  intrinsic  qualities.  Further,  the  merits  of  widely 
differing  climates  for  the  pulmonary  invalid,  should  be  decided  with 
reference  to  the  general  fitness  of  the  individual,  rather  than  from  arbi- 
trary considerations  pertaining  alone  to  the  pathologic  condition.  Sug- 
gestions will  be  presently  made  as  to  the  relative  importance  of  the 
individual  factors  in\-olved,  as  well  as  to  the  general  principles  to  be 
observed  in  the  selection  of  climate. 

While  the  removal  of  animal  heat  through  the  influence  of  external 
conditions,  represents  perhaps  the  most  important  physiologic  action 
attributable  to  climate,  other  reactions  of  great  interest  to  physicians 
have  been  found  to  take  place  as  the  direct  result  of  diminished  atmos- 
pheric pressure.  A  vast  amount  of  research  relative  to  the  effect  upon 
the  body  of  exposure  to  rarefied  air  in  high  altitudes,  has  been  con- 
ducted by  many  chstinguished  German,  French,  and  Italian  physiol- 
ogists following  the  publication  of  the  admirable  monograph  of  Bert 
in  1878.  It  is  possible,  within  the  limits  of  this  chapter,  to  review  but 
briefly  the  general  conclusions,  which,  developed  as  a  result  of  their 
systematic  study,  may  be  regarded  for  practical  purposes  as  free  from 
error.  While  it  has  been  demonstrated  that  nearly  all  functions  of 
the  body  are  influenced  more  or  less  by  residence  in  high  altitudes, 
a  few  physiologic  facts  have  been  established,  which  are  far  reaching 
in  their  significance.  Zuntz,  Loewy,  Muller.  and  Caspari  have  recently 
called  attention  to  the  influence  of  lessened  barometric  pressure  in  high 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       677 

altitudes  upon  tissue  cfmnge.  It  has  been  shown  that  nitrogenous 
material  is  assimilated  with  greater  ease  in  moderate  altitudes, 
especially  under  conditions  of  physical  exercise.  The  stimulation  of 
proteid  metabojism  is  found  to  take  place  even  in  slightly  elevated 
regions  of  from  1000  to  2000  feet,  although  more  pronounced  in  the 
higher  altitudes.  In  extreme  elevations  the  process  is  reversed,  the 
height  of  the  turning-point  varying  in  accordance  with  the  peculiarity 
of  the  individual.  It  thu.s  appears  that  the  degree  of  rapidity  of  the 
oxidizing  processes  results  not  (lirectly  from  the  amount  of  o.xygen 
supplied  at  different  altituilcs,  but  inthcr  from  the  increased  demand 
of  the  tissues  by  virtue  of  usMxiatcd  (  Hiiuitic  conditions. 

Dr.  Henry  Sewall,  in  intcrj)! cling  sumo  of  the  ob.servatioi}s  and  ex- 
periments bearing  upon  the  rvlution  of  oxi/gen  tensions  in  the  air  and  in 
the  blood,  has  called  attention  to  the  fact  that,  under  ordinary  conditions 
of  life,  there  is  containetl  in  the  blood  far  more  oxygen  than  is  actually 
required  for  the  performance  of  metabolism.  The  weakness  of  the  bond 
of  union  between  the  oxygen  of  the  blood  and  the  hemoglobin  of  the  red 
corpuscles  is  well  known,  but  the  effect  upon  this  combination  of  dimin- 
ished pressure  at  moderate  altitudes  remains  somewhat  unsettled.  It  is 
doubtful  if  variations  in  the  capacity  of  the  blood  to  absorb  oxygen  at 
different  elevations  are  sufficient  to  explain  the  development  of  fimc- 
tional  disturbances  commonly  attributable  to  altitude.  It  is  clear  that 
the  element  of  time  in  connection  with  pht/sical  rest  constitutes  the  all- 
important  consideration  in  the  adjustment  of  the  organism  to  diminished 
pressure.  In  this  event  the  system  apparently  suffers  no  embarrass- 
ment from  any  supposed  effect  of  the  lowered  barometric  pressure  upon 
the  combination  of  oxygen  with  the  hemoglobin. 

A  practical  unanimity  of  opinion  has  been  recorded  by  all  observers 
as  to  the  influence  of  altitude  upon  the  absolute  number-  of  red  blood- 
corpuscles.  There  is  uniformly  noted  an  immediate  increase  in  the 
blood  count  upon  ascending  to  a  higher  level,  but  opinions  are  very 
conflicting  as  to  the  interpretation  of  this  fact.  Definite  substantiation 
is  lacking  for  the  alluring  theory  that  the  deficiency  of  the  oxygen  in 
the  air  is  compensated  for  by  an  increase  of  oxygen  in  the  blood  through 
stimulation  of  the  blood-making  apparatus.  Certain  it  is,  however,  that 
the  red  blood-corpuscles  are  actually  increased  in  number  in  high  alti- 
tudes, and  also  that  the  amount  of  hemoglobin  is  augmented  very  appre- 
ciably. The  apparent  effect  of  lowered  atmospheric  pressure  upon  the 
blood-forming  apparatus  is  of  much  interest  in  connection  with  the 
stimulation  of  metabolism. 

Studies  of  variation  in  blood-pressure  at  different  altitudes  have 
generally  resulted  in  harmonious  conclusions  as  to  the  fall  of  arterial 
pressure  with  increasing  elevation.  The  diminution  of  pressure  is 
usually  exaggerated  by  physical  exercise,  which  also  exerts  a  signifi- 
cant influence  upon  the  pulse-rate.  Upon  removal  to  high  altitudes  the 
latter  is  noticeably  accelerated,  and  upon  exercise  becomes  dispropor- 
tionately more  rapid  and  weak  than  at  sea-level.  This  influence  of 
diminished  atmospheric  pressure  upon  the  pulse  has  been  shown  to  be 
subject  to  great  variations  in  individual  cases,  and  under  proper  con- 
ditions of  management  to  be  susceptible  of  adjustment,  provided  the 
system  is  not  crippled  too  seriously  by  disease.  The  results  of  Sewall's 
observations  upon  venous  blood-pressure  in  Denver  show  a  positive 
increase  at  a  level  of  5280  feet  as  compared  with  sea-level. 


678  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 

In  general,  the  respiratory  rate  is  accelerated  in  proportion  to  the 
diminution  of  atmospheric  pressure.  The  depth  of  the  respirations 
is  also  increased  under  similar  conditions.  A  certain  amount  of  vesic- 
ular dilatation  takes  place  from  the  increased  tension  in  the  alveoli  as  a 
result  of  the  more  pronounced  inspiratory  efforts.  Increased  circum- 
ference of  the  chest,  however,  from  continued  residence  in  mountain- 
ous regions  is  not  associated,  as  a  rule,  with  increased  vital  capacity. 
Here,  however,  the  question  of  individual  adaptation  constitutes  an 
essential  feature,  the  character  of  the  respiratory  excursion  and  the 
degree  of  alveolar  dilatation  being  subject  to  much  variation. 

The  influence  of  cUminished  atmospheric  pressure  upon  the  nervous 
system  is  at  times  marked  in  different  individuals  according  to  the 
degree  of  their  adjustment  to  changed  barometric  conditions,  and  their 
response  to  the  increased  demands  for  heat-production.  The  nature 
of  the  effect  upon  the  nervous  S3^stem  is,  therefore,  dependent  to  some 
extent  upon  the  accompanying  change  in  metabolism  and  nutrition. 
According  to  the  adaptability  of  the  individual  and  the  influence  of  all 
the  climatic  attributes  upon  the  general  tone,  the  resulting  action  upon 
the  nervous  system  may  be  described  as  either  stimulating,  or  irritating 
and  exhausting.  The  bracing,  invigorating  effect  is  undoubtedly 
caused  by  the  enhancement  of  tissue  change,  the  stimulated  activity 
of  the  heart  and  lungs,  and  the  influence  of  the  intense  solar  heat  and 
illumination  upon  the  skin.  It  may  be  stated  parenthetically  that 
l^rofound  physiologic  effects  are  produced  liy  the  influence  of  sunlight. 
In  dry,  elevated  regions  the  sunlight  is  abundant,  prolonged,  and  intense, 
the  number  of  cloudy  days  being  comparatively  few.  On  account  of 
the  slight  amount  of  moisture  in  the  air,  the  radiant  heat  of  the  sun  is 
much  greater  than  the  temperature  of  the  air.  But  little  intervening 
moisture  is  present  to  absorb  the  heat,  and  marked  differences  of  tem- 
perature are  appreciated  between  the  clirect  sunshine  and  shade,  as  well 
as  between  day  and  night.  As  a  result  of  the  tliathermancy  of  the  air, 
the  therapeutic  value  of  the  sunshine  is  undoubtedly  enhanced  to  some 
extent. 

Irritability  with  functional  exhaustion  sometimes  takes  the  place 
of  exhilaration.  Among  individuals  with  unstaWe  nervous  tempera- 
ments there  may  ensue  restlessness,  overstimulation  to  physical  exer- 
tion, insomnia,  or  impairment  of  mental  energy  and  depression. 
While  admitting  the  not  infrequent  exhibition  of  these  unfavor- 
able symptoms  strictly  among  neurasthenic  patients,  it  is  desired 
to  emphasize  the  conviction,  as  stated  in  a  previous  chapter,  that 
exaggeration  of  such  nervous  manifestations  is  not  entirely  referable 
to  the  effects  of  altitude.  In  many  instances  associated  conditions 
pertaining  to  the  environment  and  method  of  living  are  responsible,  to  a 
considerable  extent,  for  the  development  of  nervous  disturbances.  It 
is  not  altogether  the  actual  elevation  above  sea-level,  but  the  knowledge 
of  the  change  of  altitude  and  the  anticipation  of  abnormal  sensations 
that  determines  the  character  of  subsequent  .symptoms.  Clinical 
experience  in  Denver  has  shown  that  the  expectation  of  a  disturbed 
nervous  equilibrium  on  the  part  of  tlic  jiuticnt  has  often  represented 
an  important  agent  in  the  develdinneut  of  lu'rvous  symptoms,  which  in 
turn  have  disappeared  upon  proper  reassurance  and  the  inauguration  of 
a  suitable  regime.  It  is,  nevei'theless,  true  that  among  a  comparativel.v 
small  class,  disturbing  nervous  influences  are  actually  exerted  upon 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       679 

arrival  in  high  altitudes.  Unpleasant  effects  often  disappear,  however, 
as  a  result  of  the  progressive  adjustment  of  vital  processes  to  changed 
conditions  through  the  influence  of  rest.  The  appropriateness  of  moder- 
ate degrees  of  altitude  for  the  various  classes  of  pulmonary  invalids  will 
be  presently  discussed. 

In  concluding  a  review  of  the  physiologic  action  of  certain  climatic 
attributes  upon  body  functions,  it  is  fitting  to  submit,  as  a  logical 
sequence  of  thought,  the  general  proposition  that  climate  may  fail  to 
render  its  beneficent  aid  to  the  unfortunate  consumptive  only  when  the 
victim  of  the  disease  indulges  in  fatal  procrastination,  errs  grievously  in 
climatic  selection,  or  rejects  in  toto  the  accompanying  advantages  of  a 
suitable  regime.  Applying  the  principles  of  deductive  logic  to  the 
established  action  of  atmospheric  conditions  upon  the  organism,  it 
seems  impossible  to  deny  the  benefits  accruing  to  pulmonary  invalids 
from  subjection  to  the  immutable  influence  of  appropriate  climates. 

CLINICAL  TESTIMONY 

The  second  affirmative  propo.sition  relative  to  the  claim  of  climate 
as  a  therapeutic  agent,  consists  of  the  accumulated  mass  of  clinical  evi- 
dence in  substantiation  of  its  value.  For  obvious  reasons  it  is  well- 
nigh  impossible  to  compare  satisfactorily  the  results  observed  in  climatic 
resorts  with  those  reported  from  sanatoria  in  unfavoi'able  regions. 
Attention  has  been  called  to  the  vastly  differing  conditions  obtaining 
in  the  so-called  favorable  climates  and  in  local  sanatoria  for  incipient 
cases.  Statistical  observations  for  comparative  purpo.ses  are,  indeed, 
of  doubtful  efficacy,  unless  conditions  aside  from  climate  are  practically 
identical.  In  analyzing  the  results  obtained  in  different  localities,  the 
opportunities  for  error  are  so  numerous,  as  to  vitiate  completely  any 
conclusions  which  are  based  alone  upon  statistical  investigation. 
Recourse,  therefore,  must  be  taken  to  the  ripe  experience  of  trustworthy 
clinicians,  who  have  been  privileged  to  enjoy  ample  opportunities  for 
observation  and  are  thus  qualified  to  entertain  judicial  opinions.  The 
evidence  in  favor  of  climate  derived  from  such  non-partisan  sources  has 
been  found  so  irrefutable  as  scarcely  to  warrant  repetition. 

Strangely  enough,  even  the  most  bitter  opponents  of  climate  are 
wont  to  display  unconsciously  marked  inconsistencies  of  precept  as  well 
as  of  practice.  An  eminent  authority,  in  a  recent  book  upon  "  Pulmo- 
nary Tuberculosis,"  places  himself  upon  record  as  ardently  opposed  to 
the" current  idea  as  to  the  eflficacy  of  climate,  only  to  retract,  in  later 
pages,  through  numerous  admissions,  regarding  its  many  desirable  fea- 
tures. In  the  section  of  his  book  devoted  to  climate  general  negative 
propositions  are  advanced,  as  shown  by  the  following  brief  extracts :  "  This 
deeply  rooted  idea  of  the  necessity  of  cluui.m'  oC  climate  for  all  sufferers 
from  pulmonary  tuberculosis  is  erroneous  oil  the  face  of  it.  .  .  .  Sana- 
toria have  been  built  in  many  parts  of  tliis  rountry  and  of  the  wliole 
civilized  world.  Their  climates  are  of  almost  every  description,  yet 
their  results  are  similar.  Their  success  in  no  way  deiieiid:-  upon  their 
elevation,  upon  their  proximity  to  the  sea,  nor  upon  aii\  ijuulit)  pos- 
sessed by  the  air  of  their  locality.  Speaking  from  a  clo.se  olwerxation 
of  a  number  of  patients,  who,  after  undergoing  a  cour.se  of  sanatorium 
treatment  at  home,  subsequently  sought  various  distant  health  resorts, 
I  can  assert  that  in  no  single  instance  was  the  progress  of  the  disease 
distinctly  affected  by  the  change  of  climate.     In  the  case  of  patients 


680  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

who  were  doing  well  at  home,  recovery  appeared  to  be  in  no  way  hastened 
by  the  influence  of  a  selected  climate  abroad.  In  the  case  of  patients 
who  were  doing  badly  in  this  country,  a  removal  to  a  recognized  health 
resort  did  not  succeed  in  arresting  the  downward  progress."  The 
untenability  of  the  position  assumed  is  made  apparent  by  his  following 
statements,  which  in  relation  to  the  above  appear  quite  equivocal. 
"  We  like  the  treatment  to  be  carried  out  in  a  locality  whose  air  is  pure 
and  bracing,  but  moderately  dry.  It  is  possible  that  the  more  fully 
the  climate  possesses  these  qualities,  the  more  rapid  will  be  the  recovery 
of  the  consumptive.  .  .  .  Theoretical  considerations  tell  us  that 
the  air  of  towns  is  not  favorable,  and  there  is  every  reason  to  believe 
that  recovery  is  expedited  by  placing  the  patient  in  pure,  uncontami- 
nated  air.  ...  In  the  same  way  as  regards  other  qualities  of  the 
air  the  majority  of  consumptive  patients  are  benefitted  by  a  bracing  air. 
In  so  far  as  the  appetite  and  other  vital  processes  are  sensibly  quick- 
ened in  a  bracing  climate,  there  must  be  an  advantage  in  conducting 
the  treatment  in  such  an  air.  ...  I  would  only  say,  in  regard  to 
excessively  moist  conditions  of  the  atmosphere,  that  while  most  con- 
sumptives are  unaffected,  a  certain  small  number  find  that  their  coughs 
and  difficulties  of  breathing  are  increased.  ...  In  regard  to  soil 
we  are  probably  right  when  circumstances  afford  us  a  choice  in  select- 
ing one  of  gravel  or  sand.  ...  It  will  be  seen,  therefore,  that  a 
pure  and  bracing  air,  with  a  dry,  warm  soil  and  free  exposure  to  sun, 
are  of  relative  advantage.  ...  A  large  rainfall  makes  the  open-air 
life  less  easy.  .  .  .  Sunshine  in  general  acts  as  a  germicide  and 
must,  therefore,  have  a  beneficial  action  upon  the  patient's  atmosphere. 
.  .  .  It  is  generally  agreed  that  better  results  are  obtained  in  san- 
atoria during  the  winter  than  in  the  summer.  The  majority  of  our 
consumptive  patients  tell  us  that  they  are  better  suited  by  cold  than 
by  hot  weather.  .  .  .  Patients  whose  pulmonary  tuberculosis  is  of 
the  catarrhal  type,  with  much  bronchitis  or  perhaps  with  emphysema 
and  asthma,  often  respond  well  to  open-air  treatment,  but  they  are 
susceptible  in  the  matter  of  climate  and  do  better  in  one  locality  than 
in  another.  ...  In  the  case  of  patients  who  are  able  to  indulge 
themselves,  by  all  means  let  us  allow  them  to  pass  the  winter  where 
the  open-air  life  can  be  followed  with  the  greatest  amount  of  comfort 
and  pleasure." 

Despite  the  derogatory  character  of  the  opening  statements  relative 
to  the  role  of  climate  in  the  treatment  of  tuberculosis,  no  stronger  sub- 
sequent indorsement  of  its  influence  could  be  asked  even  of  its  most 
active  supporters.  The  conclusions  expressed  are  eminently  rational,  and 
in  line  with  the  opinions  long  entertained  by  all  climatotherapeutists, 
but  are,  nevertheless,  strongly  contradictory  to  the  introductory  asser- 
tions. It  so  happens  that  a  great  majority  of  the  assailants  of  climate 
are  responsible  in  their  writings  and  actual  practice  for  similar  incon- 
sistencies. In  the  language  of  Dr.  F.  I.  Knight.  "  If  weather  conditions 
make  no  difference,  why  do  patients  improve  so  much  more  at  one  season 
than  at  another?  If  it  makes  no  difference,  why  are  all  of  us  so  anxious 
to  get  our  patients  a  residence  upon  dry  soil,  with  a  sunny  exposure  and 
protection  from  the  strong  winds?"  "If  sunlight  is  good  at  all,  why 
is  it  not  better  to  have  twenty-five  or  more  days  of  it  per  month  than 
to  have  ten  or  twelve  or  less?" 

It  is,  indeed,  difficult  to  comprehend  how  any  negative  argument 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS      681 

can  develop  concerning  the  great  value  of  climate  in  the  treatment  of 
consumption,  provided  there  is  instituted  a  proper  selection  of  cases 
and  a  conjoined  attention  to  mode  of  life.  If  the  doctrine  of  outdoor 
living  means  anything  as  directed  toward  the  pulmonary  invalid,  it 
means  that  the  best  results  are  to  be  obtained  through  its  most  complete 
fulfilment.  It  follows  that  the  fullest  conception  of  a  proper  method 
of  open-air  existence  can  bes:ttisl':iitonly  ciniilucted  only  in  those  regions 
affording  the  maximum  aniouin  ol  mih-Iiihc,  with  associated  warmth, 
dryness,  and  rarefaction.  If  ;i  ,suit;ililu  n'^iniu  alone  is  capable  of  pro- 
ducing a  perceptible  improvement  in  incipient  cases,  how  much  greater 
and  more  enduring  results,  among  a  larger  number  of  cases,  advanced 
though  they  be,  may  be  obtained  by  precisely  the  same  manner  of  life, 
plus  the  beneficent  influence  of  climate.  It  appears  that  a  far  more  im- 
proved mode  of  life  can  be  enacted  in  an  appropriate  climate,  than  in  less 
favored  regions,  by  reason  of  the  added  opportunities  for  outdoor  living. 
If  a  system  of  regimen,  necessarily  incomplete  in  moist,  cloudy  regions, 
is  good,  a  well-nigh  perfect  adherence  to  these  principles,  in  a  land  of 
perpetual  sunshine,  invigorating  air,  inspiring  scenerj',  and  blue  sky 
is  certainly  better.  May  it  not  be  asserted,  therefore,  that  a  consistent 
regard  for  the  very  principles  upon  which  depend  negative  claims,  neces- 
sarily carries  with  it  an  almost  incontrovertible  argument  in  favor  of 
climatic  change  for  a  large  number  of  cases? 

It  must  be  insisted  that  there  is  something  in  climate  entirely  apart 
from  these  factors  of  sunshine  and  dryness  incident  to  favorable  regions. 
If  to  these  attributes  be  added  diminished  atmospheric  pressure,  there 
are  exerted  certain  intrinsic  influences,  cUstinctive  of  the  locality,  mark- 
edly favoring  the  attainment  of  satisfactory  results.  Reference  is  made 
to  the  increased  metabolism  from  the  more  perfect  sy.stem  of  heat- 
abstraction,  and  the  general  stimulating  effect  upon  the  muscular  and 
nervous  systems.  In  addition,  the  influence  of  altitude  in  wisely  cho.sen 
cases  has  been  shown  to  produce  an  increase  of  red  blood-corpuscles  and 
hemoglobin,  to  promote  vesicular  dilatation,  to  effect  improvement  in 
the  vigor  of  the  circulation  and  respiration,  and  to  involve  digestive 
and  nutrient  changes  of  vast  import. 

Aside  from  such  considerations  as  the  foregoing,  may  be  mentioned 
the  value  of  the  psychic  element  involved  in  all  changes  of  residence. 
This  may  react  for  good  or  evil  according  to  the  sauacity  displayed 
by  the  medical  attendant.  Admitting  a  proper  sclcitimi  cif  cases  and 
provision  for  a  suitable  environment,  there  may  develop  factors  of  no 
little  value  in  the  novelty  of  new  surroundings,  change  of  food,  scenery, 
custom,  companionship,  the  relief  from  cares  and  responsibilities  at 
home,  and  all  the  interest  that  attaches  to  a  new  country,  with  its 
stir  and  energy.  The  good  results  obtained  in  unfavorable  localities 
among  early  cases  do  not  constitute  an  argument  against  the  greatly 
increased  benefits  to  be  derived  by  a  much  larger  class  of  patients,  as  a 
result  of  the  same  watchful  observation  in  an  appropriate  climate. 
Many  instances  of  enduring  arrest  have  taken  place  among  patients  for 
whom  a  rigid  adherence  to  sanatorium  regime  was  utterly  impossible. 
A  very  considerable  proportion  of  the  invalids  observed  in  health  resorts 
are  financially  unable  to  observe  a  strict  system  of  daily  living.  By 
virtue,  however,  of  pronounced  climatic  advantages,  they  are  permitted 
to  perform  light  work,  and  at  the  same  time  to  secure  a  marked  prolong- 
ation of  life,  or  an  eventual  arrest  of  the  disease. 


682  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 

Recognizing  the  comparative  raritj'  with  which  consumption  has 
originated  for  generations  in  the  midst  of  certain  climatic  conditions, 
the  relative  frequency  of  its  development  and  the  rapidity  of  its 
progress  in  other  places,  it  should  follow,  as  a  logical  sequence,  that 
climate  must  take  its  place  as  an  important  factor  in  subsequent  efforts 
to  secure  arrest.  It  should  be  borne  in  mind  that  a  few  climates 
still  exist  where  tuberculosis  is  very  rarely  indigenous  in  spite  of  the 
existence  of  some  factors  that  might  reasonably  be  expected  to  produce 
an  increase  of  native  cases.  It  is  apparent  that  there  are  offered  to  pul- 
monary invalids  better  facilities  for  improvement  in  the  midst  of  influ- 
ences which  have  prevented  the  development  of  the  disease  in  others, 
than  under  exposure  to  the  same  conditions  that  have  been  conducive  to 
its  origin  at  home.  The  same  process  of  reasoning  may  be  extended  in 
its  application  to  the  more  remote  future  of  the  consumptive.  This  leads 
inevitably  to  the  conclusion  that  the  individual,  "once  a  consumptive, 
always  a  consumptive,"  possesses  the  inviolable  right  to  be  placed,  if 
possible,  in  the  midst  of  a  new  and  more  advantageous  environment.  He 
should  be  afforded  the  greatest  degree  of  protection  against  renewed 
tuberculous  activity,  and  offered,  at  the  same  time,  in  addition  to  oppor- 
tunities for  recreation  and  social  advantage,  facilities  for  industry  and 
business  enterprise.  In  the  midst  of  an  active  civilization  in  favorable 
climates  the  invalid  may  be  permitted  to  engage  eventually  in  a  useful 
and  prosperous  career. 

This  course  of  remark  is  presented  merely  as  an  appeal  for  an  impar- 
tial consideration  of  the  subject  in  the  interests  of  the  invalid  alone. 
The  contention  is  made  that  while  some  cases  may  be  expected  to  do 
well  under  proper  supervision,  even  if  deprived  of  the  advantages  of 
climate,  and  that  others  are  inappropriate  for  such  change,  yet  an 
enormous  class  is  justly  entitled  to  receive  its  benefits. 

CASES  APPROPRIATE  FOR  CLIMATIC  CHANGE  IN  GENERAL 

It  is  hardly  necessary  to  define  in  detail  the  character  of  cases 
embraced  in  this  general  class.  A  somewhat  broad  and  comprehensive 
grouping  of  those  for  whom  some  climatic  change  is  indicatetl  includes — 

1.  All  those  with  moderate  infection,  who  are  not  prevented  from 
leaving  home  by  financial  embarrassment  or  other  equally  cogent 
reasons. 

2.  Those  in  a  similar  physical  condition,  though  with  but  a  meager 
monthly  allowance,  provided  sufficient  accurate  information  is  obtained 
in  advance  concerning  suitable  accommodations  at  an  expense  within 
their  limits. 

3.  Those  admittedly  dependent  upon  their  own  efforts  for  support, 
but,  nevertheless,  with  such  slight  pulmonary  involvement  as  to  permit 
the  performance  of  outdoor  work  in  some  favorable  region  where  employ- 
ment may  be  assured. 

4.  Those  with  considerably  more  advanced  trouble,  but  favored 
by  a  cheerful,  sensible  temperament,  affluence,  determination  to  succeed, 
an  aliiding  hope  with  desire  for  climatic  change,  a  read}'  compliance  with 
instructions,  and  an  apparent  easy  adaptation  to  new  surroimdings. 

That  this  grouping  of  cases,  subject  to  qualification  according  to 
modifying  individual  factors,  is  reasonably  correct  has  been  shown  by 
experience  in  favorable  localities  where  remarkable  results  are  often 


CLIMATE    IX    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       683 

oljtaiiied  in  advanced  cases,  and  among  those  with  exceedingly  limited 
resources. 

It  thus  follows  that  upon  the  basis  of  actual  results,  an  assuring 
welcome  may  be  extended  to  some  who  are  no  less  worthy,  if  less  for- 
tunate, than  their  fellows  in  their  equipment  and  opportunities.  It 
must  not  be  understood,  however,  that  those  hopelessly  ill  or  utterly 
impoverished  should  be  encouraged  to  seek  climatic  change.  For  these, 
the  erection  of  State  and  municipal  sanatoria  along  lines  elsewhere  sug- 
is  obligatory,  practical,  and  economic. 

Class  1. — In  explanation  of  the  somewhat  arbitrary  and  comprehen- 
sive grouping  of  cases  with  moderate  infection  and  a  comfortable  finan- 
cial status,  it  should  be  borne  in  mind  that  the  essence  of  this  particular 
phase  of  the  subject  relates  exclusively  to  the  best  possible  provision  to 
be  made  for  such  cases.  An  enormous  class,  who  are  intensely  anxious 
to  avail  themselves  of  every  rational  opportunity  to  recover  from  their 
disease,  appeal  to  their  medical  advisers  for  nothing  less  than  that  which 
affords  the  maximum  assurance  of  ultimate  recovery.  Cases  such  as 
these,  willing  to  engage  in  the  prolonged  struggle  which  is  destined  so 
frequently  to  be  a  test  of  their  fortitude,  with  restoration  to  health  as 
the  vital  issue,  surely  deserve  such  favorable  facilities  as  will  insure  the 
greatest  probability  of  final  success.  The  obligation  of  the  physician  is 
not  fulfilled  by  advising  merely  what  is  admittedly  good,  but  is  only 
discharged  by  urging  what  is  actually  the  very  best  for  the  individual 
case.  It  is  not  a  question  of  the  possibility  of  securing  arrest  at  home 
or  within  a  local  institution,  but  whether  such  an  environment  of  itself 
is  the  method  most  likely  to  accomplish  this  result.  The  physician,  in 
assuming  to  direct  the  destinies  of  his  well-to-do  consumptive,  should 
make  a  practical  application  of  the  condition  to  himself  and  advise  in 
accordance  with  the  course  he  would  pursue  under  similar  circumstances. 
When  such  is  the  case,  little  doubt  can  exist  as  to  the  promptitude  and 
certainty  of  action.  The  sweeping  assertion,  therefore,  that  patients  of 
this  class  should  be  permitted  to  enjoy  the  benefits  of  climatic  change, 
is  ba.sed  upon  the  fundamental  principle  that  these  individuals  pos.sess 
an  indisputable  right  to  receive  that  early  unrestricted  consideration  and 
advice,  which  an  actual  experience  has  demonstrated  to  be  the  safest  and 
most  conservative. 

Class  2. — This  division  embraces  the  large  middle  class,  with  moder- 
ate infection,  but  limited  finances.  Such  patients,  though  greatly 
handicapped  by  lack  of  means,  are  not  absolutely  impecunious,  and  in 
many  instances  not  dependent  for  support  upon  themselves  alone.  It 
frequently  happens,  that  relatives  are  enal)led  to  render  such  assistance 
that,  by  the  practice  of  rigid  economy,  the  patient  is  offerer!  definite 
assurance  of  improvement  from  an  inexpensive  sojourn  in  a  laAorable 
climate.  It  is  absolutely  essential,  however,  in  justilii-ition  of  such 
change,  that  authentic  information  should  be  secured  in  adx  unic  as  to  the 
actual  expense  necessary  to  provide  apprdpriatc  arconinKidatious.  The 
question  must  lie  plainly  reviewed  with  tlic  patient  and  fanul\-  hi  all  its 
phases,  according  to  the  individual  conditicm-  in  fon-e.  Derision  as  to 
climatic  change  must  be  made  strictly  upon  the  special  merits  of  the 
physical  condition  and  attendant  circumstances.  Experience  has  shown, 
over  and  over  again,  that  a  limited  financial  status  is  no  insuperable 
barrier  to  recovery  in  health  resorts,  provided  there  is  instituted  a  wise 
preliminary  guidance  and  subsequent  supervisory  direction.     The  real 


684  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 

solution  of  the  problem  for  these  people  consists  of  the  opportunities  at 
their  disposal  in  favorable  regions.  The  position  of  the  medical  attend- 
ant in  advising  a  journej'  to  a  distant  clime  for  such  patients  is  fraught 
with  much  responsibility.  A  justification,  however,  for  this  course  is 
found  in  the  definite  knowledge  of  the  ready  facilities  for  their  reception 
within  the  bounds  of  their  hmited  resources.  Admitting  such  provi- 
sion, there  can  be  no  argument  as  to  the  expediency  of  offering  to  this 
class  reasonable  opportunities  for  securing  a  restoration  of  health  and 
resumption  of  earning  power. 

Class  3. — This  group  embraces  individuals  who,  although  to  a  great 
extent  dependent  for  support  upon  their  own  efforts,  are,  nevertheless, 
in  such  physical  condition  as  to  justify  light  outdoor  employment.  The 
practical  consideration  obtaining  among  such  patients,  is  the  fact  that 
the  performance  of  work  is  more  or  less  obligatory,  irrespective  of  their 
location.  This  being  true,  it  is  obvious  that  their  chances  for  recovery 
are  materially  enhanced  bj^  residence  in  favorable  climates.  For  these 
people  the  observance  of  a  suitable  regime  is  quite  out  of  the  question, 
and  if  work  they  must,  it  is  eminently  desirable  that  employment  be 
secured  under  the  most  advantageous  circumstances.  It  has  been 
demonstrated  repeatedlj'  that  a  large  proportion  of  incipient  cases 
without  expectoration,  or  bacilli,  now  frequently  admitted  to  local  sana- 
toria, constitute  but  little  danger  to  the  community,  and  yet  with  slight 
financial  assistance  in  an  appropriate  climate  are  not  too  ill  to  engage 
in  some  occupation  with  a  reasonable  assurance  of  improvement.  Such 
a  happ}-  result  is  far  less  likely  to  attend  their  continuous  struggle  for 
existence  amid  unfavorable  surroundings. 

Cla^s  4. — This  group  comprises  patients  who,  though  suffering  from 
advanced  infection  sufficient  to  render  prognosis  doulitful  in  any  cli- 
mate, nevertheless  are  endowed  with  favorable  temperamental  condi- 
tions and  adequate  resources.  The  necessarily  prolonged  separation 
fiimi  family  and  relatives,  the  knowledge  of  the  grave  possibilities,  and 
tlie  physical  discomfort,  in  manj^  cases,  would  influence  a  deciding  vote 
against  the  hardships  of  an  extended  journey,  were  a  welcome  extended 
to  such  individuals  by  sanatoria  nearer  home.  In  ^•iew  of  the  inability 
of  patients  of  this  class  to  gain  admission  to  closed  local  institutions, 
almost  the  only  remaining  hope  is  from  climatic  change.  The  actual 
proposition  to  be  faced  by  patients  is  the  fact  that  they  have  but  little 
to  lose  by  recourse  to  this  move,  and  perhaps  everything  to  gain.  Con- 
versely, after  a  progressive  decline  throughout  a  prolonged  period  at 
home,  they  have  no  valid  reason  to  anticipate  better  results  in  the 
future  than  in  the  past  under  the  same  conditions,  hence  every 
rational  incentive  for  a  sanely  directed  climatic  change.  It  is  but 
fair  to  state  that  this  should  not  be  decided  upon  without  a  frank 
recital  of  the  situation  to  the  patient  and  friends,  and  a  full  appreciation, 
on  their  part,  of  the  utter  uncertainties.  Neither  should  it  be  under- 
taken without  provision  having  been  made  to  permit  the  subsequent 
elaboration  of  an  intelligent  regime.  Attention  has  been  called  in 
previous  pages  to  the  remarkable  results  sometimes  achieved  among 
patients  concerning  whom  no  reasonable  hope  for  recoverj'  could  be 
entertained  at  the  time  of  arrival. 

It  is  important  to  emphasize  the  folly  of  sending  hopelessly  advanced 
indigent  patients  to  health  resorts.  While  well-to-do  desperate  cases 
are  not  of  necessity  debarred  from  the  possibility  of  final  arrest  after 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       685 

several  years  of  patient  endeavor,  destitute  consumptives  similarly 
afflicted  are  not  offered  tlie  same  opportunities  for  securing  arrest.  The 
interests  of  sucii  patients  are  in  no  wise  subserved  by  sending  them  to  a 
far  country  to  battle  against  great  odds  among  strangers  and  often  amid 
grossly  unfavorable  surroundings.  While  the  physicians  and  philan- 
thropic citizens  of  open  health  resorts  are  ever  ready  to  lend  their  aid 
to  worthy  impoverished  consumptives,  the  fact  remains  that  it  is  no 
kindness  to  send  such  cases  away  from  home.  Furthermore,  it  must  be 
remembered  that  the  influx  of  phthisical  patients  in  all  stages  of  the 
disease  and  in  direst  financial  distress,  constitutes  an  economic  problem 
not  to  be  ignored  by  the  inhabitants  of  climatic  resorts.  A  large  class  of 
advanced  pulmonary  in\alids,  with  no  conception  of  their  individual 
needs,  are  compelled  to  struggle  for  a  livelihood  in  order  to  supply  the 
most  pressing  necessities  of  life.  Others  are  doomed  to  disappointment 
in  securing  work,  and  either  are  obliged  to  seek  assistance  in  order  to 
return  home,  or  become  a  charge  to  the  local  community.  Serious 
hardship  is  sometimes  inflicted  upon  the  resident  employe  and  his 
family  in  being  forced  to  compete  with  the  cheap  labor  of  the  unfor- 
tunate consumptive.  The  presence  of  hopeless  consumptives  in  a 
community  often  tends  to  inculcate  public  pessimism  as  to  the  possi- 
bility of  ultimate  arrest,  and  to  retard  charitable  impulses  for  the  relief 
of  those  less  seriously  afflicted.  As  a  rule,  the  advanced  consumptive 
with  extremely  limited  resources  does  not  profit  from  the  hardships 
necessarily  assumed  by  himself,  as  well  as  imposed  to  some  extent  upon 
others.  Allusion  is  made  to  those  of  his  family  who,  by  dint  of  personal 
sacrifice,  manage  to  extract  a  mere  pittance  from  their  savings  in  order 
to  contribute  toward  a  portion  of  his  support,  or  who  assume  obligations 
representing  a  grievous  burden  to  be  borne  through  many  years.  In 
view  of  the  indiscriminate  character  of  the  patients,  who  seek  relief  in 
health  resorts  after  months  or  years  of  unnecessary  delay,  it  is  no 
wonder  that  resident  physicians  are  clamorous  in  their  demands  for  an 
earlier  appreciation  of  the  importance  of  climatic  change,  and  for  the 
display  of  added  care  in  determining  the  suitability  of  the  individual  to 
the  locality. 

CONSIDERATIONS  RELATIVE  TO  CLIMATIC  SELECTION 

In  the  course  of  the  preceding  remarks,  an  effort  has  been  made  to 
emphasize  the  importance  of  a  discriminating  choice  of  climate  according 
to  the  physiologic  adaptation  of  the  individual.  It  has  been  made  clear 
that  no  single  locality  is  appropriate  for  all  classes  of  pulmonary  invalids 
who  may  demand,  upon  the  merits  of  their  condition,  some  form  of 
climatic  change.  Many  consumptives  exhibiting  similar  physical  signs 
and  subjective  symptoms  differ  essentially  in  their  constitutional  vigor, 
while  some  present  certain  important  complications.  Thus,  among 
patients  apparently  in  the  same  class,  marked  differences  exist  in  the 
indications  for  climatic  selection.  Often  the  decision  with  reference 
to  radically  diverse  types  of  climate  should  be  influenced  by  the  age 
of  the  pulmonary  invalid,  the  previous  habits,  envii-onment,  race, 
temperamental  peculiarities,  and  complications.  CHinatcs  which  for 
many  individuals  exert  a  general  stimulating  and  tonic  action  are  found 
to  produce  pronounced  irritability  or  depression  in  others.  Per  contra, 
certain  regions  noted  for  their  enervating  and  relaxing  influence  upon 


b&b  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

the  majority  of  pulmonary  invalids  are  found  to  exercise  a  soothing 
and  bracing  effect  upon  some  with  disturbed  nervous  equilibrium. 
Thus  it  follows  that  the  selection  of  climate  for  those  suffering  from 
pulmonary  tuberculosis  should  be  based  primarily  upon  an  intelligent 
conception  of  the  constitutional  requirements  of  the  individual.  There 
is  demanded  an  accurate  knowledge  of  the  damage  already  wrought  by 
the  destructive  process,  and  a  working  familiarity  with  the  atmospheric 
conditions  in  force  at  the  various  health  resorts  and  their  physiologic 
effects.  A  not  unimportant  factor  is  the  nature  of  the  accommodations 
available  for  patients  in  different  localities.  In  addition  to  the  facilities 
for  the  proper  reception  of  cases,  some  importance  may  attach  to  the 
general  character  of  the  medical  supervision  in  different  resorts.  In 
many  instances  determining  features  relate  to  the  opportunities  offered 
for  diversion  and  recreation,  social  advantages,  educational  facilities, 
and  industrial  pursuits.  The  above  considerations  may  sometimes 
turn  the  scale  in  favor  of  a  locality  exhibiting  climatic  virtues  in  no  way 
superior  to  those  possessed  by  other  resorts  embraced  in  the  same 
general  region. 

Of  all  the  several  factors  worthy  of  thoughtful  review,  none  is  more 
important  than  the  degree  of  individual  response  to  the  heat-dissipation, 
which  is  subject  to  great  variation  in  different  localities.  It  has  been 
stated  that  the  abstraction  of  heat  is  most  efficient  in  moderately  cold, 
dry,  and  variable  climates  in  elevated  regions.  In  mountainous  dis- 
tricts a  certain  disadvantage  attaches  to  the  occasional  high  velocity 
of  the  wind  and  the  presence  of  dust,  but  these  conditions  do  not  offset 
the  high  value  of  the  combined  climatic  influence  upon  metabolism. 
While  in  general  the  most  favorable  climate  for  consumption  is  that 
exhibiting  attributes  of  dryness,  sunshine,  moderate  altitude,  diminishecl 
atmospheric  pressure,  and  variability,  this  combination  in  its  physiologic 
demands  upon  the  organism  is  not  suited  to  the  needs  of  all  patients. 
The  occasional  lack  of  adaptation  has  led  to  repeated  assertions  that 
dry,  cool  mountain  climates  are  appropriate  only  for  patients  in  early 
stages,  with  robust  constitution  and  slight,  if  any,  functional  impair- 
ment. At  the  same  time  the  contraindications  for  residence  in  moderate 
altitudes,  as  laid  down  by  various  writers,  are  legion.  Man}'  statements 
of  this  character  are  scarcely  in  accord  with  the  results  of  experience. 
It  is  true  that  patients  with  incipient  infection,  endowed  with  sturdy 
and  vigorous  constitutions,  without  other  organic  derangement,  do 
particularly  well  in  high  altitudes.  In  such  cases  the  respon-se  of  the 
organism  to  external  atmospheric  conditions  is  usually  immediate, 
despite  indulgence  in  moderate  physical  exercise.  In  addition,  a  large 
class,  with  a  perceptible  reduction  of  vitality,  disordered  digestion,  and 
defective  assimilation,  often  evince,  under  conditions  of  rest,  a  degree 
of  response  far  beyond  the  anticipation  of  medical  advisers.  This 
capacity  for  favorable  reaction  occurs  in  many  instances  in  the  presence 
of  extensive  damage  to  pulmonary  tissue.  On  the  other  hand,  persons 
with  extremely  low  vitality,  enfeebled  circulation,  and  greatly  impaired 
digestion,  when  exposed  to  such  climatic  conditions,  often  suffer  an 
aggravation  of  the  functional  derangement. 

It  follows  that  low  elevations  and  equability  of  temperature,  with 
varying  degrees  of  moisture,  are  admirably  suited  to  the  needs  of  a  con- 
siderable class,  irrespective  of  the  duration  or  activity  of  the  tuberculous 
process.     These  climatic  attributes,  in  connection  with  warmth,  ma.y 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       687 

produce  among  some  patients  a  stimulating  effect  upon  the  general 
system,  with  promotion  of  metabolism  and  nutrition.  As  a  rule, 
patients  displaj'ing  excessive  destruction  of  pulmonary  tissue,  resulting 
in  marked  diminution  of  respiratory  capacity,  thrive  only  in  warm, 
dry  regions  having  a  high  barometric  pressure.  Many  sufferers  from 
dry  bronchitis,  asthma,  and  extensive  emphysema  demand  not  only 
residence  at  low  elevations,  but  also  the  added  elements  of  equability 
and  moisture. 

Generally  speaking,  the  young  show  a  much  greater  adaptability 
to  mountainous  cliiiiatcs  than  the  aged.  At  the  latter  extreme  of  life 
the  vitality  is  (limiiiishcd,  the  cardiac  force  weakened,  the  circulation 
enfeebled,  and  the  walls  of  the  arteries  likely  to  be  more  or  less  thickened. 
For  such  patients  the  climatic  needs  consist  of  warmth,  equability, 
and  absence  of  elevation,  even  if  there  is  considerable  moisture.  In 
the  same  way  persons  in  middle  age,  who  for  prolonged  periods  have 
been  the  victims  of  perverted  metabolism,  may  exhibit  such  pathologic 
change  in  the  heart,  arteries,  and  kidneys  as  to  preclude  subjection  to 
the  cold  and  variability  of  temperature  incident  to  high  altitudes.  For 
these  people,  with  declining  powers  of  heat-product  ion,  caution  should  be 
exercised,  because  of  their  inability  to  respond  to  t  he  iiKicascd  demands. 

It  is,  of  course,  recognized  that  advanced  degeiuTatnc  ciianges  in  the 
heart,  arteries,  or  kidneys  must  disparage  recourse  to  the  cold,  dry  air 
of  elevated  plateaus.  It  does  not  follow,  however,  that  the  existence 
of  all  forms  of  organic  heart  disease,  regardless  of  their  character  or 
degree  of  compensation,  necessarily  prohibits  residence  in  moderately 
elevated  regions.  It  is  often  impossible,  in  a  a:i\(ii  la-e,  to  estimate 
with  any  degree  of  accuracy  the  probable  effect  ol  low  liujimietric  pres- 
sure upon  the  heart.  Patients  with  well-defined  vahular  lesions,  but 
with  adequate  compensation,  frequently  show  no  symptoms  whatever 
upon  ascending  to  very  elevated  regions.  Upon  the  other  hand,  indi- 
viduals disclosing  upon  examination  no  evidence  of  organic  change, 
occasionally  exhibit  disturbed  cardiac  function  at  an  altitude  of  from 
6000  to  8000  feet.  It  would  a.jjpear  that  the  vital  consideration  is  not  a 
refinement  of  diagnosis  relative  to  the  existence  of  an  obscure,  pei'fectly 
compensated  valvular  lesion,  but  rather  an  attempt  to  jud^e.  as  closely 
as  possible,  concerning  the  relation  of  heart  power  and  work.  It 
is  apparent  that  flabby,  dilated  hearts,  pronounced  myocarditis, 
even  without  dilatation,  and  acute  inflammatory  conditions  involving 
the  endocardium  or  pericardium.,  should  debar  patients  from  visiting 
mountainous  regions.  In  cases  with  uncomplicated  regurgitant  lesions 
or  with  moderate  arteriosclerosis,  admitting  of  reasonable  doubt  as  to 
the  advisability  of  change  to  moderate  altitudes,  tentative  recourse  to 
slightly  elevated  regions  represents  a  judicious  and  conservative  course. 

Consumptives  suffering  from  advanced  kidney  disease  are  unsuited 
for  high  altitudes,  and,  in  fact,  inappropriate  for  climatic  change  of  any 
kind  in  the  hope  of  securing  appreciable  prolongation  of  life.  It  is 
important,  however,  to  refrain  from  rendering  an  unfavorable  prognosis 
upon  the  basis  of  a  simple  albuminuria.  In  this  connection  the  follow- 
ing case  is  of  some  interest: 

A  man,  twenty-seven  years  old,  a  patient  of  Dr.  Biggs,  with  tubercu- 
lous family  history,  consulted  me  November  11,  1895,  immediately 
upon  arrival  in  Colorado.  His  illness  had  developed  in  November, 
1893,  following  a  severe   attack  of   grip.      He  spent  a  large   portion 


boo  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

of  the  following  year  in  the  Adirondacks,  and  exhibited  material 
improvement  in  all  respects.  Upon  coming  under  nw  observation  the 
nutrition  was  but  slightly  impaired,  and  the  general  condition  excellent. 
There  were  signs  of  consolidation,  however,  in  the  left  upper  lung,  with 
moist  rales  from  the  apex  to  the  fourth  rib  and  to  the  middle  of  the 
interscapular  space.  The  examination  of  the  urine  disclosed  a  large 
amount  of  albumin,  without  casts  or  other  abnormal  sedimentary  find- 
ings. There  was  displayed,  however,  a  remarkable  diurnal  fluctuation 
in  the  amount  of  albumin.  The  urine,  taken  at  different  hours  of  the 
day,  was  frequently  examined,  and  while  albumin  was  found  to  be 
present  in  variable  amount  in  each  specimen,  the  quantity  in  mam- 
instances  represented  but  a  slight  trace.  The  albuminuria,  after  per- 
sisting for  nearly  a  year,  disappeared  altogether,  and  has  not  returned 
during  a  residence  of  twelve  years  in  Denver.  The  patient  secured  a 
complete  arrest  of  the  tubercidous  process  and  has  been  engaged  in  an 
active  business  career. 

Even  the  presence  of  hj'aline  and  granular  casts,  with  or  without 
a  slight  amount  of  albumin,  is  insufficient  to  wan-ant  an  unreservedly 
bad  prognosis.  The  recognition  of  hyaline  or  granular  casts  in  persons 
beyond  the  prime  of  life  is  by  no  means  uncommon,  while  among  younger 
people  an  irritative,  rather  than  a  purely  degenerative,  process  may  be 
suggested  in  some  instances.  As  a  rule,  the  early  stages  of  chronic 
interstitial  nephritis  among  pulmonary  invalids  indicate  the  advisability 
of  equability,  dryness,  and  high  atmospheric  pressure  rather  than  resi- 
dence in  mountainous  districts.  While  a  certain  number  of  nephritic 
consumptives  may  be  expected  to  yield  indifferent  results  if  exposed  to 
the  variability  of  temperature  incident  to  higher  altitudes,  a  few  are 
found  to  improve  satisfactorily  in  dry,  moderately  elevated  regions. 

It  is  frequently  urged  that  residence  in  high  altitudes  is  contraintli- 
cated  for  the  consumptive  by  the  coexistence  of  such  nervous  disturb- 
ances as  severe  and  protracted  headaches,  insomnia,  irritability,  and 
hysteria.  The  reason  adduced  is  the  supposed  resulting  aggravation 
of  the  nervous  symptoms,  and  the  consequent  imfa\-orable  influence 
upon  the  cour.se  of  the  tuberculous  infection.  The  inference  is  implied 
that  improvement  in  the  nervous  derangement  must  precede  any  change 
for  the  better  in  the  lungs.  This  is  not  invariably  the  case,  although 
upon  general  principles  it  is  wise  to  maintain  as  perfect  a  nervous  equi- 
librium as  po.ssible.  Iii  the  majority  of  cases  the  acquirement  of 
an  increased  nutrition  must  antedate  any  appreciable  progress  either 
toward  the  arrest  of  the  tuberculous  process  or  the  alleviation  of  func- 
tional disturbance.  The  reported  observations  of  Dr.  H.  T.  Pershing, 
of  Denver,  which  coincided  with  the  published  views  of  the  late  Dr. 
Eskridge,  indicate  the  slight  influence  of  altitude  upon  purely  functional 
nervous  disorders.  With  this  opinion,  my  own  experience  relative  to 
nervous  disturbances  among  pulmonary  invalids  accords  somewhat 
closely.  It  has  not  been  altogether  uncommon,  however,  to  note  an 
aggravation  of  neurasthenic  tendencies.  apparnUhi  the  result  of  altitude, 
but  these  manifestations  have  been  chiefly  observed  amid  an  unsuitable 
environment.  While  pronounced  nervous  disturbances  offer  a  serious 
obstacle  to  improvement  in  an}-  climate,  the  pulmonary  infection  must 
be  regarded  as  the  paramount  issue,  the  functional  derangement 
demanding  greater  attention  to  details  of  management  rather  than 
change  of  climate.     Among  neurotic  invalids  residing  in  high  altitudes. 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       CS9 

the  psychic  influence  attending  change  of  immediate  surroundings,  with- 
out the  slightest  difference  m  climatic  conditions,  is  otten  productive  of 
remarkably  gratifying  results.  It  is  true,  however,  that  many  neurotic 
invalids  are  likely  to  reflect  greater  credit  upon  the  therapeutic  manage- 
ment, if  subjected  to  the  soothing  sedative  influence  of  warmth,  mois- 
ture, and  equability. 

Fe\-ci'  is  s<iiiiciimes  regarded  as  an  important  consideration  in  a 
decision  ;i.-  to  h  choice  of  climate,  high  altitudes  being  supposed  to 
exert  a.  (Iclctriinus  influence.  If  other  iduditions  are  not  distinctly 
contraimhi  Hi  nr  dl  climatic  change,  the  presence  t>\  \f\cv  i^icatl)-  eniplia- 
sizes  the  e\])e(licqi(  y  lit  ,  ucli  a  mOve.  No  Ul'eatel-  fdlly  call  lie  exliiljited 
than  the  jiract  ice  111  wailing  for  the  fever  to  suliside.  uii<ler  the  ini~taken 
notion  that  residence  in  ia,\-(>ra.bl<'  reuioiis  will  prdiliice  an  increase  of 
the  temperature  elevalion.  An  iin]iiiita.nt  factor  in  the  reduction  of 
fever  is  the  niaiiitenaiice  of  complete  rest  iii  the  open  air  duriiii;  as 
many  hours  as  pos.ible.  Ihe  elabor.-ition  of  >iich  ;i  s\steni  of  living 
must  be  more  complete  in  localities  peinutt  iiiii  the  inaxinuini  amount 
of  sunshine.  It  follows  that  the  es.cniial  consideration  in  such  cases  is 
the  avoidance  of  any  unnecessary  dekiy  in  the  selection  of  climate  in 
accordance  with  the  manifold  plia. cs  of  the  case. 

Excessive  bronchial  irritation  also  is  regarded  l>y  some  as  a  con- 
traindication for  sojourn  in  luidi  and  dry  climatic  resorts  with  \aiiable 
temperatures.  OccaMoiuill>'  this  aiiuoyiu.i;  mauilestat  ion  is  tempor.urily 
aggravated  in  elevated  regions,  but  tlie  ),o,-sib|e  initalixe  effect  upon 
the  bronchial  mucous  membrane  is  by  no  means  a  criterion  of  the  jirecise 
influence  of  the  climate.  The  efficiency  of  the  la.ttei-  is  measuicd  solely 
"rse  of  the  tulierculous  jirocess, 
cial  importance.  The  bronchial 
or  significance,  and  in  nearly  all 
lioi'ation  under  a  proper  regime. 

-al.ilit\-   of   warm,   equable,   and 

.■..iiuain(rica,ted. 

u|i]Micd  lo  jurni.sh  a  contraindi- 

s.  is  le^s  likel\'  to  ensue  in  such 

rturi'  from  home  is  delaved  until 

a  brief  iulerval  ha,-  ela|i>e,l  alter  the  heinonlia-e  lia.s  ceased. 

This  subject  ha-  been  discussed  in  some  detail  in  connection  with 

Symptoms. 

In  general,  it  may  be  assumed  that  the  special  contraindications  for 

sojourn  in  ele\-ated  regions  are  not  so  numerous  and  urgent  as  some 

have  been  led  to  believe. 

POPULAR   LOCALITIES 

Professor  Moore  has  stated,  "  Within  the  1  ndad  confines  of  the  United 
States  there  are  many,  but  not  all.  shades  and  \arieties  of  climates." 
A  cUversity  of  climatic  conditions  is  incN'ital  )le  a.~  :i  result  of  the  enormous 
size  of  the  couiiti\',  the  e-seiitial  differences  in  the  m'iiei:il  toiiography, 
the  presence  ol  laiue  mienor  boilies  of  water,  and  the  pidximitv  to  the 
Atlantic  a.nd  I'acilic  ()cea.iis.  It  is  well  to  call  attention  briefly  to  the 
general  characteristics  peculiar  to  a  few  isolated  localities. 

The  predominant  features  obtaining  in  the  Adirondack  Mountains 


with  reference  to 

the  subsequent    co 

which  is  the  only 

consideration  of  esp 

irritation  in  sucii 

cases    is  often  of   mil 

instances  is  susce 

plil.le  of  decided  am 

Onlv  when  tin-  .-. 

.nditi.ui  i^ass.iciated 

])atiiol<ii;ic  .■Ikui-i 

cs   iiiv.ilving  the   pul 

which   in   them-r 

l\i's   siu^ucst     the   a(h 

moist  climates,  a,i 

■e  moder.'ite  altllilde- 

Pulmonary  \\r 

morrhaiii',  |ioiMil:irh- 

cation  for  residei 

ice    ill    ele\-;i,te(l    rc'io 

places  than  al   -e: 

,-leVel.  provided    d^p^ 

690  PROPHYLAXIS,    GEXERAL    AXD    SPECIFIC    TREATMENT 

of  New  York  are  an  altitude  approximating  2000  feet,  a  comparatively 
small  number  of  sunny  days  during,  the  year,  moderate  humidity 
of  the  atmos]ihere.  and  an  abundance  of  clouds,  fog,  snow,  and 
rain.  The  winters  -.iw  nitenscly  cold,  but  the  air  at  this  season  is  much 
drier  than  durini;  warm  weather.  The  summers  are  cooler  and  more 
invi,niir:itinu  than  iiian\-  ]Hirtions  of  New  York  State,  but  the  heat  is 
sonu'tiiiics  ii|j|iics>i\c,  r\('ii  in  this  mountainous  resort.  The  soil  is 
sand\-,  and  lurcsts  of  |uii('  aliound.  This  region  is  known  to  possess 
man\-  al  ti-art  n'lis  lur  the  ptiliniinary  invalid  in  the  novelty  of  sur- 
roundiiius,  licainiiul  scriici y,  i;ciii-ial  . li\ cit iiig  influences,  opportunities 
for  rcciratiuii,  ami  \ri\  cxcclliMit  aci'(  niinii "  lations.  Here  is  situated  the 
achiHialile  .Vdin.iidack  (',.iiai;i>  Saiiai-iiuiii,  the  creation  of  Dr.  E.  L. 
Trudeau.  The  cssciiiial  I'limatic  aM  lilmtcs,  however,  do  not  vary 
materially  in  thcii'  ucmaal  i)li\  si..liiuic  actinn  from  these  obtaining  in 
otliei-  licalth  I'psoit-  scattcrci  t hruufilidui  the  New  England  States, 
althduuli  Ideal  (liffiTPiii'cs  ot'  iiiiudr  importance  are  recognized.  This 
locality  has  for  many  years  oiijuycd  a  well-deserved  reputation  as  a 
place  df  sdidiiiii  fur  pulmonary  invalids.  The  remarkable  beauty  of 
the  lake-  and  furests  and  the  excellent  facilities  for  fishing,  render  the 
Adirdudai-k  ici^ion  a  pleasurable  and  appropriate  resort  for  those  whose 
physical  iiiliriiiities  tlo  not  preclude  indulgence  in  outdoor  sports.  The 
hi.iilily  ^ai  i-taetory  results  so  frecjuently  attained  in  the  Adirondacks 
from  >\>teinaiie  medical  supervision  are  worthy  of  especial  mention. 
The  same  is  true  of  the  Loomis  Sanatorium  for  Consumptives  under 
the  management  of  Dr.  Herbert  Maxon  King,  and  situated  at  Liberty, 
Sullivan  County,  New  York. 

Asheville,  N.  C,  is  situated  at  an  elevation  approximately  identical 
with  that  of  the  Adirondacks.  The  adjacent  country  is  mountainous 
and  heavily  wooded.  As  a  a:eiieral  rule,  the  temperature  is  compara- 
ti\ely  equable,  althoiioh  extreme  fluctuations  sometimes  take  place. 
The  relative  humidii  \  is  liiiih  at  all  times  of  year.  The  winters  are  cold, 
although  much  less  -d  tlian  in  the  Adirondacks,  while  the  summers  are 
not  oppressive.  The  sm  >u  .  w  liich  remains  for  many  weeks  in  the  Adiron- 
dacks, melts  speedil\'  in  Aslieville,  leaving  the  ground  exceedingly 
mudily  for  consideialile  ixaidils.  This  beautiful  city,  situated  upon  an 
elevated  plateau  witli  niduntains  but  a  few  miles  distant,  rising  an 
additional  l.-.OI)  leet,  ..ffers  advanlai;.-  Id,-  ■,  lai-e  elas-^  df  pulmonary 
invalids.  Tliei-e  ai'e  many  line  residence-,  laiinly  hotels,  and  exception- 
ally well-appointed  lioanlin^-liouses.  Tlie  W  inyali  Sanatorium,  under 
the  direction  of  Dr.  Kai-1  \on  Hnck,  has  pn,ioyed  a  long  and  useful 
existence.  The  excellent  accommodations  outside  of  sanatoria  render 
Asheville  jiarticularly  inviting  to  tlio.se  not  desirous  of  residing  within 
a  clo-ed  in-tilution.  The  mountain  drives  in  almost  all  directions 
in  thi'  ,-ui  loundin.s;  country  are  unusually  attractive,  while  the  scenery 
throuiihout  the  entii-e  district  hel]is  to  make  this  resort  especially 
delightful  l)Oth  during  the  winlei'  and  the  summer  months. 

Aiken,  S.  C,  at  an  altitude  .if  neaily  600  feet,  is  possessed  of  a  sandy 
soil,  moderate  dryness  of  the  atmosi)here,  and  equability  of  temperature. 
There  is  but  little  wind  and  there  are  a  considerable  number  of  sunny 
days.  The  winters  are  warm  and  delightful,  but  the  summers  are 
exceedingly  oppressive.  The  hotel  accommodations  are  exceedingly 
good,  while  the  Aiken  Cottage  Sanatorium  provides  excellent  facilities 
for  pulmonary  invalids  to  pursue  an  open-air  existence.     This  institu- 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       691 

tion,  under  the  supervision  of  Dr.  C.  F.  McGahan,  is  one  of  the  oldest 
sanatoria  in  the  United  States. 

Those  portions  of  Florida  which  in  former  years  enjoyed  a  remark- 
able prestige  as  a  place  of  sojourn  for  pulmonary  invalids  during  the 
winter  months,  are  characterized  by  warmth,  moisture,  equability,  and 
high  atmospheric  pressure.  In  the  interior  of  the  State  the  atmosphere 
is  not  particularly  moist  and  the  sunshine  fairly  abundant,  but  the 
summers  are  quite  enervating:  and  wet. 

The  climate  of  soulliciii  (':ilitni-iii;i  is  of  a  somewhat  tropical  charac- 
ter, being  depressinii,  sunny,  nmisi ,  and,  upon  the  whole,  equable.  Con- 
siderable differences  obtain  in  various  portions  of  this  I'egion,  according 
to  the  proximity  of  the  ocean,  or  a  location  in  the  drier  mountainous 
sections.  The  climate  at  the  seashore  is  essentially  moist,  and  is  quite 
undesirable  for  consumptives  of  any  class.  In  Ln.s  Angeles  but  a  very 
few  hours  of  the  twenty -four  may  be  regarded  as  rcasi  mablx-  dry.  Along 
the  southern  coast,  both  in  summer  and  winici',  f  he  Inimiilit y  is  marked, 
and  the  fog  noticeably  dense  in  the  earlier  puitiuu  of  the  day.  A 
foggy  spell  of  seventeen  days'  duration  is  recorded  at  iSanta  Barbara  in 
May  and  June  of  1903.  The  humidity  of  the  fogs  penetrating  inland 
from  the  coa.st  is  considerably  greater  than  that  nf  Boston  or  New 
York.  Marked  diurnal  variatiims  of  Iminidity  are  luuiid  in  resoits  .along 
the  coast  of  the  Pacific.  \\  hiie  e(|u,iliilit,\-  of  temiieiatnic,  sunshine, 
dryness  of  soil,  with  but  little  wiiui  movement,  are  inipuiiant  climatic 
features,  the  vast  amount  of  moisture  in  the  air  constitutes  so  im- 
portant a  characteristic  as  to  result  in  frequent  tendency  to  chilling, 
and  to  interfere  seriously  with  a  continuous  out-of-door  existence.  A 
satisfactory  conformity  of  the  organism  to  the  irreiiulaiity  of  demands 
for  heat-production  is  sometimes  quite  out  of  (lie  (|uestion.  It  is 
difficult  to  understand  for  precisely  what  class  dt  ]i\ihnonary  invalids, 
if  any,  the  climate  along  the  sdiillurn  niasl  n<  ( 'alil'i'inia  is  really  adapted. 
Upon  the  other  hand,  in  the  luountainnus  i-euions  there  are  freedom 
from  fog,  diminished  humidit\,  and  al'sem-e  uf  e.vtreme  heat  or  cold, 
resulting  in  less  general  dejiression  and  iclaxatinn.  In  Dr.  Pottenger's 
Sanatorium  at  Monrovia  and  in  the  ISarlmv  Sanatorium  near  Los 
Angeles  the  general  environment  and  character  of  accommodations 
are  well  suited  to  a  class  of  pulmonary  invaliils. 

The  arid  regions  of  Arizona  possess  climatic  features  of  great  value 
to  the  climatotherapeutist.  While  ceilain  characteristics  are  common  to 
the  entire  territory,  a  noticeable  difference  is  observed  in  the  altitude 
of  various  portions.  Sandy  deserts  abuund  in  a  (hstrict  far  reni(i\-ed 
from  large  bodies  of  water.  The  counti->-  is  bii)]<en  mure  oi'  less  by 
numerous  mountain-ranges  with  inter\eniiii;  \  alleys.  Tlie  distinctive 
climatic  attributes  are  eqiinbiUti/  of  tern /n  nilmi ,  r.ftriinc  ili'iiniss,  a 
maximum  amount  of  sunshine,  with  a  consideraMi'  \ariatiiin  df  atmos- 
pheric pressure  according  to  location.  An  altitude  nl  Mod  teet  is  fnund 
at  Phoenix;  of  2400  feet  at  Tucson,  and  of  rtUOO  feet  at  ( )racle,  an  attrac- 
tive resort  in  the  Galiuro  Mountains,  tiiiity-fi\( 
It  is  stated  that  Phoenix  lias  the  sukiIIisI  jiircd 
the  greatest  amount  of  simshim  of  .an}-  city  in  the 
The  air  is  remarkably  clear,  and  the  d.-iys  are,  up. 
ful.     During  the  winter  months  the  conditions  ar( 

to  the  physical  well-being  of  a  large  class  of  pulmonary  invalids.     At 
this  season  of  the  year  a  comfortable  out-of-door  existence  is  permitted 


les    tVu 

n,   Tucs,,n. 

'   of  In,. 

Ill  id  III/  and 

■ailed   a 

rid  re-i.in. 

he  who 

le,  d.^hght- 

•uliarly 

conducive 

b9^  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMEXT 

almost  continuously,  while  the  nights  are  cool  and  refreshing.  A 
summer  sojourn  in  this  place  is  prohibited  by  the  intense  debilitating 
heat.  Important  drawbacks  to  many  of  the  manifest  advantages  of 
Arizona  are  the  comparatively  short  season  during  which  the  climatic 
conditions  are  particularly  advantageous,  the  remoteness  and  inaccessi- 
bility, the  occasional  prevalence  of  high  winds,  the  dust-storms,  and 
the  frequent  difficulty  in  securing  suitable  accommodations  in  some 
resorts. 

The  features  of  climate  prevailing  in  El  Paso,  Texas,  and  in  southern 
New  Mexico,  in  comparison  with  those  enumerated  as  characteristic  of 
Phcenix,  are  a  diminished  dryness,  increased  elevation,  and  lessened 
equability.  There  is,  however,  a  large  percentage  of  possible  sunshine, 
but  slight  relative  humidity,  a  dry,  sandy  soil,  and  cool  nights.  Owing 
to  tlic  laifie  ;u-ea  included,  with  important  differences  of  altitude  and 
latitude  ill  \aii()iis  regions,  a  considerable  divergence  of  climatic  con- 
ditiiins  is  fduml.  The  general  features,  however,  are  those  of  dryness, 
sunshine,  iliiniiiished  atmospheric  pressure,  and,  in  the  elevated  regions, 
a  iKiticealilc  \  aiiability  of  temperature.  A  detracting  influence  from 
the  >;eiiei,il  exrellence  of  the  climate  relates  to  the  occurrence  of  high 
wind-.  Iiiilijiiii;  in  susjionsion  enormous  clouds  of  dust,  which  are  some- 
times driNeii  wuli  exti-enie  velocity.  These  winds  are  more  prevalent 
durinu  ilie  winter  .iinl  spring  months,  and  exert  an  undeniable  effect 
upon  the  iierxnii^  .-ysteiu  of  ]iulmonary  invalids,  who,  for  this  reason, 
are  prone  tn  exiiiUil  at  times  eniisiilei-alile  irritability  of  temperament. 
The  climate,  especial!)-  in  tlie  nortlieiu  portion  and  in  the  more  elevated 
regions,  is  deridedly  in\-ii;ojatin<i  and  (■oii(|uci\-e  to  increased  metabo- 
lism. An  outdoor  life  is  peiniitted.  as  a  lade.  during  the  entire  day. 
Save  in  the  more  elevated  localities,  the  heat  i)roduces  pronounced 
relaxation  during;  the  siiniinei-,  often  necessitating  the  removal  of 
many  phthisical  patients  to  the  cooler  regions  of  Colorado. 

While,  fof  oli\iou~  n-.i-ons.  it  is  not  desired  to  exploit  the  virtues 
of  any  particular  .State,  it  must  be  admitted  that  in  Colorado  is  found 
the  nearest  approach  to  climatic  idealism  for  ih(>  m-eat  nuiss  of  pul- 
monary invalids.  In  common  with  iiortliern  \e\\  .Mi'xico.  the  climate 
is  extremely  dry,  with  prolonged  sunshine  and  intense  solar  radiation, 
marked  diathermancy,  low  barometric  pre.ssure,  variability  of  tem- 
perature, and  moderate  winds — in  short,  all  the  combined  attributes 
which  constitute  a  favorable  climate  for  a  large  class  of  phthisical 
patients.  Colorado,  which  is  preeminently  a  land  of  sunshine  and 
dryness,  has  been  endowed  by  nature  with  a  sandy,  porous  soil,  an 
inspiring  scenery,  and  all  the  invigorating  qualities  incident  to  moder- 
ately diminished  atmospheric  pressure.  The  climate  cannot  justly 
be  reiiardeil  as  ei|iial)le.  and  in  this,  as  previously  stated,  is  concealed 
a  desiialile  feature  with  respect  to  the  regularity  and  degree  of  heat- 
abstraction. 

Among  the  disadvantages  sometimes  stated  to  obtain  from  residence 
in  this  region  are  the  extreme  cold  of  winter  and  the  high  winds  and 
dust,  olijectioii-  which,  in  point  of  fact,  are  more  fancied  than  real. 
Despite  numerous  statements  to  the  contrary  by  those  unfamiliar  with 
actual  condii  ions,  Colorado  is  indeed  a  delightful  resort  during  the  entire 
year,  on  account  of  the  remarkable  difference  obtaining  between  the 
physical  and  sensible  temperatures.  Generally  speaking,  there  is  an 
absence  of  extremes  of  heat  or  cold,  the  winters  not  being  characterized 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       693 

by  very  low  temperatures  nor  the  summers  by  excessive  heat.  During 
the  cold  season  the  weather  is  rarely  such  as  to  interfere  with  a  contin- 
uous out-of-door  existence.  At  this  time  of  year  rain  is  exceedingly 
uncommon  and  snow-storms  comparatively  infrequent.  The  winter 
cold  is  seldom,  if  ever,  depressing,  save  to  extremely  debilitated  indi- 
viduals. Upon  the  contrary,  a  general  exhilarating  effect  is  often  noted, 
as  a  result  of  which  appetite  and  digestion  are  stimulated  to  an  appre- 
ciable extent.  As  oppo.sed  to  the  enervating  sense  of  inertia  peculiar  to 
warm  regions,  the  invigorating  effect  of  a  Colorado  winter  is,  in  fact,  a 
positive  advantage.  It  must  be  concedfMl  that  at  times  a  distinct  dis- 
advantage relates  to  the  ]ir('\alriicc  cif  wiml  :iii(l  dust.  During  a  few  of 
the  spring  months,  antl  especially  in  the  al'li-iiKKin,  there  is  more  or  less 
temporaiy  annoNaiice  fioiii  those  sources,  but  it  is  seldom  that  the 
invalid  is  mil  peiiii  it  led  to  remain  in  the  open  air  upon  a  slielterinu  porch. 
These  untax  (naiili^  tactois  obtain  to  a  less  degree  than  in  Aiizona  and 
southern  portions  of  New  Mexico,  while  the  relaxation  from  heat  during 
the  summer  is  comparatively  slight.  A  desirable  feature  of  considerable 
importance  is  the  avoidance  of  necessity  for  removal  from  one  climate  to 
another  at  diffeient  seasons  of  the  year.  Such  changes  involve  not  only 
considi'ialile  expense,  inconvenience,  and  difficulty  of  securing  appropri- 
ate acconiniodaiions,  but,  above  all,  the  frecjuent  deviations  from  an 
appropriate  regime.  Instances  of  this  are  all  too  frequent  within  the  ex- 
perience of  observers  in  health  resorts  in  any  locality.  The  climate  of 
Colorado  is  in  many  respects  similar  to  that  of  the  Swiss  Alps,  though 
in  the  latter  region"  there  are  fewer  hours  of  possilile  sunshine  and  a 
severer  winter,  but  a  ilimini-lietl  amount  of  wind  and  dust. 

Climatologii-  liteialnre  abounds  with  statistical  comparisons  of 
meterologic  data.,  lallnm  attention  to  essential  differences  of  tempera- 
ture, relative  humidiix  ,  Min-lmie.  precipilation,  and  wind  mo\-eiuent  in 
Colorado,  and  vaiiou,-  <;//m  ,  /,«,//,//,>  (■njoyinii  u-iH-dismal  leputations 
as  health  resorts.  While  ]Hirlion>  of  Arizona  an<l  Xew  Mexico  exhibit 
more  dryness  and  in  some  ^l^tances  increased  e(|ual>ility  of  temperature, 
these  qualities,  though  eminently  desiraMe  in  iliemselves,  are  offset  to 
some  extent  liy  tlle  );-reater  tendeln'N'  to  wind.-  and  dust,  the  lessened 
stimulalmu  etlect  ,  the  llec<•s^it\-  of  ^ea^ona  I  clia  n;_:e.  and  nol  in  I  Vei  |nelltly 
the  existence  of  intiTior  a.cconiniod;;,!  ion,-  ('onipa,n-<,n,-  l,et\\een  the 
meteoroloiiic  condition,-  olitainiim  in  ('olorado  k^cmIs  and  eastern  locali- 
ties are  too  in\-idioiis  and  lannliar  to  just  ily  ehunieration. 

It  is  just  to  as.sei-i  thai  tliere  i,-  alniosi  no  pail  of  Colorado  where 
the  invalid  may  not  deinc  cliinaiic  oppoit  unit  les  tor  material  improve- 
ment. In  numeroii.s  coininiinitie,-  t  ln'onulioui  I  lie  Sta,te  a,inple  provision 
is  made  for  the  reception  of  \-i,-itiii;;  con.-iiinpt  ncs.  Two  localities  suit- 
able for  residcMice  diiiinn  the  entire  year  are  worthy  of  special  mention — 
Den\cr  and  ( 'ojoiado  Sjirings. 

Slight  ineiitioii  need  he  made  of  the  climatic  attributes  peculiar  to 
Denver,  which  iii  general  are  similar  to  those  .already  enumerated  as 
obtaining  in  Colorado,  but  there  are  some  essential  feature.-  i  oncerning 
which  there  has  been  more  or  less  popular  misi-onception.  Attpiition 
has  lieen  directed  from  time  to  time  to  alleged  (li.-a.<l\  antai^es  incident 
to  tlie  smoke  from  I  lie  smell  ei's  and  other  nia,ii  uf;i,ct  u  rinu  est  aMisliinents, 
the  overcrowding  of  population,  the  e-\cilenienl  inciileiit  to  the  confu- 
.sion  and  acti\ity  of  a  large  city,  the  aliseiice  of  outdoor  dhersion  and 
recreation,  and  the  difficulty  of  securing  suitable  accommodations. 


PROPHYLAXIS,    UKXEKAL    A.ND    SPECIFIC    TREATMENT 


abode.     The  Home  is  in  effect  an 


While  a  large  amount  of 
smoke  is  emitted  from  the 
chimneys  of  the  smelting  es- 
tablishments upon  the  north- 
eastern outskirts,  this  consti- 
tutes but  a  slight  objection, 
as  the  prevailing  winds  carry 
the  smoke  away  from  the  city 
to  a  great  extent.  Althougli 
a  suitalile  environment  is  not 
offered  to  the  consumptive  in 
the  thickly  settled  portion,  it 
is  im]30ssilDle  to  find  more  ideal 
conditions  tlian  can  be  secured 
in  the  readily  accessible  out- 
lying districts.  Facilities  for 
cli\ersion  and  recreation  are 
found  in  the  various  parks 
adjacent  to  the  city,  while 
for  suitable  cases  the  country 
clubs  offer  attractions  for  golf 
and  social  ]iloasures.  The  ac- 
(■(iiiiiiKHlaticiiis  for  pulmonary 
iiiNaliil-  aiv  sufficiently  ample, 
\;uiud.  Mid  appropriate  to  suit 
the  needs  of  the  most  fas- 
tidious. Provision  is  made, 
without  especial  difficulty,  for 
those  who  prefer  to  board  or 

S    domicile    themselves    in    fur- 

ci    nished  houses. 

'^  An  establishment,   known 

as  The  Home,  the  creation  of 
Rev.  F.  W.  Oakes,  has  enjoyed 
a  period  of  usefulness  during 
the  past  twelve  years.  This 
institution,  oi'octpd  at  a  cost 
of  $!'.')( ).i Kill,  i,-^  located  in  the 
less  dcii-rly  piiinilatod  portion 
of  the  111)',  a.iid  provides  ac- 
(■oiimio(lations  in  its  various 
(li'paitinciiis  for  150  patients. 
\\  iiile  tlie  pervading  spirit  is 
not  that  of  a  sanatorium 
proper,  it  is  doubtful  if  any 
institution,  wherever  located, 
can  offer  to  a  class  of  invalids 
more  of  the  material  comforts 
of  life  with  greater  opportuni- 
ties for  improvement  than  can 
be  obtained  in  this  place  of 
mmaculatelv  clean  and  attractive 


residence,  designed  for  the  exclusive  acconmiodation  of  consumptive 


CLIMATE  l.N  THE  TREATMENT  OF  PULMOXARY  TUBERCULOSIS   695 


mminiimmw 

Fii,'.   161. — A  pnrcli  iii  connection  with  the  hospital  adilit 


696 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


and  has  been  found  appropriate  for  a  large  class.  By  virtue  of  an 
unusual  environment,  patients  are  permitted  to  partake  of  its  essential 
advantages  and  at  the  same  time  conform  to  such  hygienic  restrictions 
as  may  be  imposed  in  individual  instances.  The  establishment  is  open 
to  any  practising  ph3'sician,  and,  therefore,  without  any  fixed  system 
of  sanatorium  regime.  There  is  permitted  to  any  medical  attendant, 
however,  the  exercise  of  such  supervisory  control  over  his  own  cases 
as  he  sees  fit  to  institute  or  has  the  power  to  maintain.  By  means  of 
spacious,  well-arranged  porches,  ample  facilities  are  afforded  for  outdoor 
living.  Scrupulous  attention  is  devoted  to  the  disinfection  of  apartments. 
The  Home  is  pleasingly  furnished,  and  provides  very  desirable  accom- 
modations for  people  with  limitetl  resources,  as  well  as  for  those  more 


Fig.  162. — .\iiother  porch  m  connection  with  the  hospital  addition,  Oakes  Home. 


favored  financially.  The  expense  varies  in  the  several  departments 
from  $30  to  $120  a  month,  according  to  individual  requirements  in  the 
way  of  care  and  nursing.  An  idea  of  some  of  the  pleasing  features  of 
this  institution  may  be  conveyed  by  the  accompanying  illustrations. 

Excellent  accommodations  are  also  afforded  at  the  Agnes  Memorial 
Sanatorium,  which  is  operated  as  a  closed  institution  for  the  care  of 
consumptives.  This  was  founded  through  the  generosity  of  Mr.  Law- 
rence C.  Phipps,  of  Denver,  and  is  under  the  active  management  of 
Dr.  G.  Walter  Holden. 

A  worthy  institution,  known  as  The  National  .Jewish  Hospital  for 
Consumptives,  bestows  upon  the  very  poor  who  are  fortunate  enough  to 
gain  admittance,  a  most  substantial  charity. 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS       697 


Colorado  Springs,  located  at  the  base  of  Pike's  Peak,  presents  climatic 
features  closely  resembling  those  obtaining  in  Denver.     There  is  the 


163.— The  cloister,  Oakes  Hon 


same  pro.ximity  to  the  great  plains,  the  same  alnmdance  of  sunshine, 
the  large  number  of  exceptionally  clear  days,  the  low  humidity,  and  the 


small  amount  of  rainfall.     The  altitude,  however,  is  nearlv  1000  feet 
higher,  with  a  corresponding  increase  of  variability.     There  are  high 


098  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

winds  of  somewhat  iiicreiised  prevalence  and  velocity,  the  latter  being 
about  one-third  greater  in  Colorado  Springs  than  in  Denver.  The 
disagreeable  effect  of  the  wind  is  intensified  by  fine  particles  of  irritating 
dust,  but  these  features,  as  a  rule,  do  not  represent  a  serious  oljjection. 
save  during  the  existence  of  dust-storms,  which  are  comparatively 
infrequent.  Patients  rapicUy  accustom  themselves  to  the  increased  air 
movement,  which,  if  extreme,  may  be  a\'oided  by  retiring  to  sheltered 
porches.  By  virtue  of  the  location  of  the  citj'  at  the  juxtaposition  of 
plain  and  mountain,  there  is  a  habitual  diurnal  variation  in  the  tlirection 
of  the  local  winds,  prerisely  as  takes  place  at  the  seashore.  Solly  has 
called  attention  t"  the  customary  daily  variability  of  the  wind  as  follows: 
"In  ortUnary  weatlier.  tiirougiiout  the  night,  a  gentle  breeze  blows 
from  the  north  or  northwest,  and  as  the  sun  begins  to  rise  the  wind 
shifts  eastward  and,  passing  south,  blows  from  the  southwest  during 
the  early  afternoon,  then  turning  backward  through  the  eastern  quarter, 


Fig.  165. — Home  for  nurses  connected  witli  the  Oakcs  Home. 


reaches  the  north  once  more  as  the  sun  goes  tlown,  where  it  lingers 
through  the  nii;ht.  The  velocity  of  the  wind  is  very  slight  during  the 
hours  (if  ilaikncss.  hut  increases  after  daybreak  up  to  two  or  three  o'clock 
in  the  ai'tcrunnn.  when  it  blows  with  its  maximum  force,  gradually  dying 
down  again  a<  -iiu^ct  aiiiuiiarhcs  ami  it  rctiirn-  Tri  the  northern  quarter. 
Thus  there  is  \>v  .la\  a  >ra  or  plain  liici'/r.  li\-  iiiLilit  a  shore  or  mountain 
breeze."  The  iinpulatiiiu  i>  luiiiiici-nl  laiL;rl\  ni  cnn-uniptives  wiio  have 
recovered  their  healtii  by  reason  of  sojourn  in  tins  locality.  Contrary 
to  the  statements  of  some  writers,  the  city  exhibits  a  remarkably  pleasing 
and  imposing  appearance,  particularly  in  the  residence  district.  The 
streets  are  unusuall^v  broad,  and  are  rendered  quite  attractive  by  the 
abundance  of  shade  trees.  Exceedingly  good  accommodations  may  be 
obtained  in  numerous  boarding-hou.ses.  as  well  as  in  the  Glockner  and 
Cragmor  Sanatoria,  both  of  which  are  admirably  conducted.  The  former 
has  been  in  existence  for  many  years  under  the  direction  of  the  Sisters 


CLIMATE    IN    THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS      699 


,/■■ 


of  Charity   and    provides  ac-  r 
commod;itioiis  for  about  200  ' 
patient-s.       The     latter     was  [ 
founded  in  1904  through  the 
efforts  of   the  late  Dr.  S.  E. 
Solly   and    the    senerositv    of 
Gen.    Wm.    ,1.    l'nlni,.r.     'it  is 
located  on    the    nm-kiiis    of 
the  city,  afford     cxccllrul  :ic- 
commodatiou;s  lur  iweuty-live 
patients,    and    is    under    the 
supervision     of     Drs.     C.     F. 
Gardiner,    W.   H.  Swan,   and 
H.  W.  Hoagland. 

It  is  not  to  Denver  and 
Colorado  Springs  alone  that 
the  invalid  in  search  of  health 
need  look  for  suitability  of 
climate,  attractiveness  of  ac- 
commodations, and  opportu- 
nity for  recreation.  Aci-ording 
to  seasonal  cha.u^os.  o]ipftvtu- 
nity  is  afforded  in  mlii-i-  parts 
of  the  State  for  .-inh  tempo- 
rary sojourn  as  may  suit  the 
inclinations  and  satisfy  the 
apparent  needs  of  those  for 
whom  a  rational  diversion  is 
indicated  to  break  an  other- 
wise unceasing  monotony. 
With  the  advent  of  warm 
weather  patients  may  avail 
themselves  of  the  facilities 
presented  in  various  resorts 
for  the  enjoyment  of  country 
life  and  mountain  air.  Ex- 
cellent accommodations  may 
be  obtained  at  Estes  Park, 
seventy-five  miles  from  Den- 
ver, at  an  altitude  of  about 
7000  feet.  This  park,  at  the 
foot  of  Long's  Peak,  consists 
of  a  plateau  a.boiit  ten  miles  j 
long  and  six  miles  wide,  con-  I 
tuinin,;;  imniiiieialile  hills  and  j 
valleys,  and  smiounded  by 
gigantic  mountains  witli  snow- 
clad  peaks  and  cia.uuy  pieci- 
pices.  Fifteen  years  ago  the 
late  Dr.  Ilnedi.  upon  arrival 
from  S\\il/;eilaiid.  endeavored 
to  select  in  Colorado  a  location  suitable  for  comparison  with  Davos  as  to 
climatic  characteristics,  fauna,  and  flora.     He  found  that  "a  difference 


700 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


of  2000  feet  between  Colorado  and  Switzerland  was  required  to  puv 
invalids  under  the  same  conditions."  Considerable  reseml)lance  was 
shown  between  Estes  Park  and  Davos,  except  as  to  the  factor  of  altitude. 


A.r  u  result  uf  close  meteorologic  ol)ser\-ation  he  wa>  enabled  to  call 
attention  to  a  diminished  variation  in  the  barometric  pressure  in  Estes 
Park  as  compared  with  that  of  Davos,  and  to  the  far  greater  number  of 


at  Estes  Park. 


hours  of  possible  sunshine.  A  striking  difference  in  the  humidity  was 
also  noted,  the  absolute  precipitation  in  the  Swiss  mountains  being 
considerably  in  excess,  but  the  prevalence  of  wind  decidedly  less 
marked. 


TREATMENT    OF    SPECIAL    SYMPTOMS  701 

Attention  is  sometimes  called  to  the  supposed  inability  of  invalids  to 
retui-n  home  after  an  arrest  has  been  secured  in  high  altitudes.  It  is 
hard  to  conceive  how  i-esidence  at  high  elevations  can  render  the  in- 
valid more  susccptililc  td  a  renewed  acti\-ity  nf  the  tuberculoiis  process 
upon  return  id  ihc  low  l.uids.  Even  were  tins  tiiic  !iowc\cr,  it  would 
not  militate  auuinst  prompt  recourse  to  the  f;i\-or;i.l  i|c  inlluciicc  of  in<i(ler- 
ate  altitudes.  in  no  cwiit  could  this  coiisi,l(.i;i1iou  lie  coustruiMl  us  an 
argument  a.iiahist  scndiuu  jiuticuts  to  I'lcvaii-il  icL:ions,  l.ul  merely 
against  iiermitting  tlieni  to  return  until  :i  deiinite  arrest  has  l)ecn  estab- 
lished. Furthermore,  the  vital  desideratum  in  any  case  is  an  earlj- 
restoration  to  health,  rather  than  a  regard  for  the  patient's  welfare 
after  recovery  has  been  secured. 


CHAPTER   XCVI 
TREATMENT  OF  SPECIAL  SYMPTOMS 

The  treatment  of  the  vaiious  coniplieations  ii.as  been  desci-ibed  in 
connection  with  tlieir  ilinical  manifestations.  'I  hi'  uvneial  manaLicment 
of  fever  has  been  di.s.ussed  at  leniith  m  tlie  eli.'ipier  devoied  I,,  Mixed 
Infection.  Among  the  other  symptoms  the  ireatmeni  of  wliich  is 
worthy  of  special  mention,  cough,  di.iicsiixc  di-oiilei,-.  ni^il  it -sweats, 
nervous  disturbances,  cardiac  weakness,  and  in-omiua  are  of  imporiance. 
The  treatment  of  pulmonary  hemorrhage  will  lie  considered  in  a  sejiarate 
chapter. 

COUGH 

No  single  symptom  is  comparable  with  couuii  in  its  constancy,  vary- 
ing character,  anil  dilfeiinu  mdiratioir-  Uu-  ilieiapeiitic  management. 
While  cough  is  almo:  t  always  picM'iit  to  some  extent,  there  is  often 
displayed  a  remarkable  difference  in  the  frequency,  general  cluira-cter, 
and  degree  of  severit}-.  It  has  been  shown  that  there  is  no  deiinite 
relation  between  the  intensity  of  cough  and  the  extent  or  a,cti\ity  of 
the  tuberculous  infection.  This  symptom  is  sometimes  of  minoi-  sig- 
nificance, even  in  advanced  phthisis,  and  not  infrequently  an  irnportant 
disturbing  factor  in  rarhi  cases. 

In  view  of  ilie  pergonal  element,  so  l.ar'jciv  opeiati\e  in  the  pro- 
duction and  na.nii-e  of  rouuli,  ii  follows  thai  r.iiional  pall  i;it  ix'e  manage- 
ment  shoulil    take   roulil/,;illce  of    ill(li\-i(hlal    K  llo-N-licr.-i  -  les.       The   COUgh 

is  loose,  and  atiemleil  li\  useful  expectoration  in  some  .'ii.-lances,  while 
dry,  paroxysmal,  exhaust  inu.  and  unnecessar\'  in  others.  In  rec(ii;iLition 
of  thedivei-genre  of  i  her.-ipeiii  ir  mdi.'aHon^  it  followsihat  elTorts  to  limit 

Routine  melli(HN,,l  ,aJla,\im:.-ouL:li  dioiihl  1  ,e  rii^idlv  axoal,.,!,  the  nature 
of  the  treat  ineni  ill  iiidixidnal  ra-e-  ,  lepi.tidiiiL:  l.a.ruelv  upon  tliiTa.u.sal 
conditions  and  the  a„-socuited  ilist  ui  l.a.nces.  In  ueiieral.  il  i-  desiralile 
to  reduce  to  a  minimum  the  o\ersen~iliilil >•  of  the  1  nonchial  tract. 
Among  some  invalids  jiromotion  of  expectoration  is  demanded.  |jut  in 
a  large  proportion  of  ca.ses  the  amount  of  bronchial  irritability  is  far 
in  excess  of  that  required  to  free  the  respiratory  passages. 


702  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

Preliminary  to  the  institution  of  treatment,  it  is  of  prime  importance 
to  conduct  a  critical  inquiry  as  to  the  existence  of  local  causative  factors. 
The  pharynx  should  lie  carefully  inspected  in  order  that  a  prolonged 
uvula  may  be  aminitatcd  if  necessary,  and  enlarged  follicles  upon  the 
posterior  wall  of  the  iiharyux  destroyed.  The  larynx  also  should  be 
examined,  that  areas  of  infiltration,  ulceration,  or  necrosis  may  be  sub- 
jected promptly  to  local  treatment.  The  recognition  of  cardiac  embar- 
rassment is  of  importance,  for  a  venous  engorgement  of  the  pulmonary 
circulation  often  jn'odisposes  to  the  devclojimont  of  bronchial  irritability. 
In  this  event  the  cxliibltioii  uf  nitro^lyccnn  ami  utlici-  iviiicdies  to  relieve 
the  pulmonary  ronm-iKiu  is  iiv(|iiei[i  |y  niiciidcd  l.y  M-iial  benefit.  The 
coexistence  of  ne{)hntic  tlisturlianie,  a  rheunuilic  iliathesis,  gout,  and 
chronic  alcoholism  should  be  ascertained,  and  treatment  appropriate 
for  the  underlj-ing  condition  immediately  inaugurated.  Exposure  to 
dust ,  wind,  or  smoke  should  be  restricted,  and  loud  or  prolonged  talk- 
ing enjoined. 

The  medical  advice  should  be  governed  largely  by  the  character 
of  cotigh,  the  conventional  administration  of  syrups  and  sedative  tablets, 
irrespecti\e  of  other  considerations,  being  productive  of  no  inconsider- 
able harm. 

It  is  hiuhly  inexpoflient  tn  resort  to  the  employment  of  any  agent 
not  a.li-iilutcly  (IciiuhiiIimI.  and,  above  all,  to  permit  its  use  according  to 
the  falicilul  jud-iiii-nl   ni  ihe  patient. 

As  a  rule,  ample  nieaMires  are  availalile  for  the  restriction  of  cough 
without  recourse  to  opiates.  In  all  rase,-  ui  dry  cough  with  unnecessary 
and  spasmodic  efforts  toward  the  I'xiiul-iou  of  expectoration,  detailed 
utilization  of  various  iiyuieiiir  ineasnivs  are  of  ui'ent  value.  These  par- 
oxysms have  been  described  as  occimiim  alter  liea\  >'  meals,  upon  change 
of  position,  as  arisinu  iiulie  moiiuimor  iciiiim:  for  the  nii^ht.  upon  abrupt 
alternation  of  heat  or  cokl,  upon  exjjosure  to  raw,  chilling  winds,  inha- 
lation of  smoke  or  dust,  indulgence  in  ph3-sical  exercise  or  inordinate 
laughter,  and  during  a  state  of  mental  excitability.  The  frequency  and 
severity  of  spasmodic  coui^h  are  al'-o  aggravated  to  no  little  extent  by 
dist\irliaii(<'s  of  iliuestioii  and  coii-1  ipat  ion.  It  is  at  once  apparent  that 
the  olilmatioii  oi'  the  medical  atteii.laiit  relates  not  to  the  unthinking 
admini-tr.itioii  ol  (•daii\c-.  Imt  to  the  comprehensive  reco<;nition  of  all 
infiueiire-  re-|M,n.,l,lelorthecouL;h.  u  1  let  her -eueral  or  lor.-d .  and  at  teu- 
tion  to  tlii'ir  remo\al  or  routiol.  The  di'-ree  to  wlu.-h  excessive  bron- 
chial irntabilily  with  exhau-lim;  coii-li  may  be  relieved  by  carefldly 
supervised  hygienic  measures  r-almoM  beyond  belief.  Successful  results 
are  greatly  facilitated  by  the  willin.u  coopeiation  of  the  patient,  which 
can  be  secured  only  by  a  detailed  recital  of  the  possible  causative  in- 
fluences.   ■ 

In  many  cases  complete  physical  rest  in  the  recumbent  or  semi- 
reclining  posture  sho\dd  bo  secured  for  at  least  one-half  hour  after  meals. 
This,  of  course,  is  particularly  -lilted  iinl'i  to  |iatients  whose  paroxysms 
of  cough  are  not  exrncd  upon  a-sumim:  tin-  |Mi-itioii.  It  is  especially 
appropriate  for  those  with  tlecidedly  neiMnis  temperament,  and  with 
marked  susceptibility  to  variations  of  external  iein|iera.t>ire.  It  is  impor- 
tant that  meals  should  not  be  eaten  at  tinx's  ol  menial  excitement  or  phy- 
sical exhaustion,  as  the  tendency  to  cough  and  vomit  is  then  accentu- 
ated to  a  marked  degree.  Inasmuch  as  the  coughing  at  such  a  time  is 
largely  of  reflex  origin,  it  is  often  desirable  to  restrict  the  amount  of  food 


TREATMENT    OF    SPECIAL    SYMPTOMS  703 

ingested  with  the  meals.  Many  patients  are  able  to  receive  into  their 
stomachs  a  moderate  quantity  of  food  without  excitation  of  paroxysmal 
cough,  but  exhibit,  upon  overindulgence,  distressing  reflex  irritability. 
Invalids  of  this  class  should  receive  their  food  frequently,  but  in  com- 
paratively srnall  amounts.  Bits  of  ice  may  be  held  in  the  mouth  after 
eating  if  the  tendency  to  cough  is  pronounced.  In  extreme  cases  tablets 
containing  a  small  amount  of  cocain  may  be  slowly  dissolved  in  the 
mouth,  or  the  fauces  may  be  sprayed  with  a  weak  solution. 

The  influence  of  change  in  position  is  illustrated  by  the  customary 
cough  in  the  early  morning  and  late  evening.  At  such  hours  the  need 
of  controlling  cough  is  less  apparent  than  at  other  times,  as  the  expulsion 
of  the  secretions  is  more  or  less  imperative  and  the  danger  of  reflex 
vomiting  much  diminished.  During  the  balance  of  the  day,  particularly 
after  taking  food,  the  restriction  of  severe  cough  sometimes  necessitates 
rest  in  the  upright  position,  or  at  most  reclining  slightly  in  an  invalid 
chair.  Many  patients  complain  liitterly  of  the  cough  which  ensues 
immediately  upon  lying  down  at  night,  resulting  in  the  loss  of  the  evening 
meal  from  reflex  vomiting.  This  unfortunate  occurrence  is  far  more 
apt  to  take  phu-c  whou  imalids  retire  shortly  after  food  is  ingested. 
WhUe  it  is  hiulily  (IcsiniLIc  to  -ccure  as  many  hours  of  sleep  as  possible, 
this  in  no  case  sIkhiM  take  j)rccc(lenre  over  efforts  to  control  the  paroxys- 
mal evening  cough.  In  such  cases  it  is  my  custom  to  instruct  patients 
to  partake  somewhat  sparingly  of  the  evening  meal,  and  to  retire  for  the 
night  not  until  after  the  lapse  of  several  hours.  Animated  conversation, 
music,  and  playing  and  other  forms  of  social  indulgence  are  interchcted. 
Exposure  to  the  cold  night  air  is  often  injudicious  for  this  class 
of  invalids,  even  if  at  rest  upon  the  porch.  Quiet  and  seclusion  in  a 
well-ventilated  and  not  overheated  room  are  indicated  until  such  time 
as  the  processes  of  digestion  are  well  estalijishi'd.  'i"hc  ('\riiiiiii  may 
be  spent  in  light  reading,  with  the  jiaticut  in  a  sciiiiupri;;lit  jKisture. 
Experience  has  shown  that  in  man>'  in  •ta,iicc~  the  later  lidur  of  retiring 
is  compensated  for  by  the  diminished  teiideni)-  to  cnuiili  when  the 
recumbent  position  is  finally  assumed,  by  tlie  lesser  likelihond  of  reflex 
vomiting,  and  by  the  greater  ]>r()lial)ilii>-  nf  secuiiim:  unbroken  sleep. 

In  all  cases'the  frequent  alleiiialKin  nf  luii  a-nd  cold  air  must  be 
avoided  as  far  as  possible,  and  prdtection  alTcnded  lioni  drafts,  chilling 
winds,  or  atmospheric  containinatidu  with  siudi^e  or  dust.  Physical 
exercise  and  undue  hilarity  incident  to  extdierance  of  sjiirits  nuist  be 
prohibited  until  cough  has  been  siilidued  within  reasonable  bounds. 

The  ingestion  of  copious  drafts  of  hot  water  upon  arising  in  the 
morning,  with  or  without  the  atldition  of  sodium  phosphate  or  other 
alkaline  preparation,  is  often  peculiarly  efficacious  in  i-elieving  the 
severity  and  shortening  the  period  of  morning  paroxysms. 

Subjective  control  on  the  part  of  the  patient  is  of  exceeding  import- 
ance. Invalids  should  be  taught  to  repress  the  desire  for  coughing 
unless  assured  that  the  expectoration  is  easy  of  exjiulsion.  To  a  very 
great  extent  the  frequency  of  cbugh  is  influenced  l)y  halnt,  which,  by 
the  exercise  of  firm  volition,  is  capable  of  much  restraint.  It  is  par- 
ticularly desirable,  for  obvious  reasons,  that  the  tendency  to  cough 
should  be  overcome  at  meal-time,  and  the  possibilities  for  repression 
at  this  time  are  sometimes  remarkable. 

Counterirritation  over  the  sternum  is  frequently  of  some  value  in 
the  severity  of  cough  during  acute  bronchial  exacerbations. 


704  PROPHYLAXIS,    GENERAL    AND    SPtX^IFIC    TREATMENT 

At  this  particular  period  inhalations  are  also  of  considerable  benefit, 
but  should  not  be  emploj-ed  for  over  a  few  days  at  a  time.  In  acute 
cases  the  inhalation  may  consist  of  various  combinations  of  eucalyptus, 
menthol,  thymol,  oil  of  puie,  and  phenol,  and  in  chronic  cases  of  crea- 
sote,  balsam  of  Peru,  tincture  of  benzoin,  iodin,  terebene,  etc.  During 
periods  of  excessive  irritability  considerable  imi3ro\-emeiit  is  sometimes 
afforded  by  this  means.  It  is  essential  that  tlic  mliulation  of  medicated 
steam  be  practised  in  great  moderation,  and  thut  i  lie  patient  refrain  from 
going  out-of-doors  until  at  least  one-half  hour  has  ehipscd.  The  spas- 
modic cough,  characterized  by  absence  or  tenacity  of  expectoration,  is 
favorably  influenced  in  many  cases  by  the  periodic  administration  of 
the  syrup  of  hydriodic  acid.  An  experience  of  many  vears  with  this 
agent  has  est.-tl'li-hcd  the  conclusion  that,  adminiritered  thi'ee  times  a 
day  for  varyiim  pnidds.  it  is  often  capaWe  of  lessening  the  severity  of 
cough  to  a  iiiatci  uil  i-\tfiit  and  promoting  ease  of  expectoration. 

Ill  lasc  the  idimli  iviiiains  persistent  in  sjijte  of  liygienic  measures, 
deleti'iHius  elieit  -  are  iiicN  itaM}"  obserxcd  in  the  production  of  reflex 
emesis,  iiuiiairineiit  oi  iiutiitioii,  (U  turbaiice  of  sleep,  and  diminution 
of  strength,  liuler  the.  e  ciicuin  tames  relief  should  be  afforded  within 
moderate  limits  by  the  judii'ious  employment  of  sedative  agents,  among 
whiili  coileiu  aii(l  heidui  take  the  lirst  place.  In  many  cases  codein 
may  be  lomliiiieil  to  a.il\  ania-e  with  terpin  liydrate  in  doses  of  {  and  2h 
grains  i-e-piMindy.  Iiriii:  therap\  for  the  relief  of  cough  .should  be 
restricteii  as  iinnii  as  jio:  ,  ible,  and  under  no  circumstances  should  be 
left  to  the  jutlgment  of  the  patient.  Opium  deri\'atives  may  be  admin- 
istered either  in  tablet  or  liquid  form,  but  if  the  latter  is  used,  care  should 
be  taken  to  exclude  syruixs.  on  account  of  their  pernicious  influence 
upon  iligestion.  Not  rntil  all  hope  of  recovery  has  vanished,  should  the 
comfort  of  the  jiatieiit  with  di  tressing  cough,  be  promoted  by  the  free 
exhibition  of  moiplun,  lieidin.  or  codein. 

DIGESTIVE  DISORDERS 

The  contraindications  for  excessive  feeding,  together  with  the  general 
principles  of  dietetic  treatment,  have  been  described  in  connection  with 
the  general  subject  of  superalimentation. 

The  dietetic  and  mrdirnml  iiiaiia'.:ement  of  the  various  disturbances 
of  the  gastro-intestinal  tiart  i~  attended  by  the  assumption  of  much 
responsibility,  for  on  the  pre-er\ai  nni  of  digestion  rests  the  cliief  hope 
of  the  consuinptive.  In  addition  to  the  ]  io-<il  .ilit  \'  n\  onjiiiiic  change 
in  the  alinielitarv  canal,  .■xre].!  loiial  opporl  uiiil  ie~  are  afforded  tor  the 
development  of  juurtimud  di.-order.  .\itentioii  ha,-  been  ralle<l  to  the 
apparent  incapacity  of  the  chgestive  apparatus  by  reason  of  unfortunate 
neurotic  disturbances,  sometimes  incident  to  the  course  of  pulmonary 
tulierculosis.  Allusion  has  been  made  to  the  effect  of  fever  and  toxemia 
upon  the  gastric  secretions,  and  to  the  pernicious  influence  of  indis- 
criminate stuffing,  comljined  with  restriction  of  physical  exercise.  If 
to  these  factors,  which  are  profoundly  instrumental  in  imjiairing  diges- 
tion, there  is  added  the  evil  of  injudicious  medication,  it  is  no  wonder 
that  consumptives  become  sadly  handicapped  in  their  struggle  for 
recovery. 

Acute  disturbance  of  gastric  digestion,  which  not  infrequently  results 
from  indiscretions  of  diet,  suggests  the  wisdom  of  immediate  food  restric- 


TREATMENT    OF    SPECIAL    SYMPTOMS  705 

tion,  and  the  administration  of  calomel  in  small  doses  until  from  one  to 
two  grains  have  been  taken.  This  should  be  followed  by  a  mild  saline 
laxative  upon  the  ensuing  morning.  The  calomel  is  especially  indicated 
if  the  tongue  is  furred  and  the  breath  heavy.  After  thorough  move- 
ments of  the  bowels  and  practical  starvation  for  twenty-four  hours, 
increasing  amounts  of  food  should  be  permitted,  but  starches,  sweets, 
and  fats  should  be  temporarily  avoided.  The  essential  therapeutic 
indications  are  as  stated,  the  free  evacuation  of  the  bowels  from  the 
exhibition  of  calomel,  rest  for  the  gastro-intestinal  tract,  liquid  nourish- 
ment for  one  or  two  days,  a  gradual  resumption  of  solid  food,  and  the 
administration  of  bitter  tonics,  which  in  many  cases  should  be  combined 
with  hydrochloric  acid.  As  stated  elsewhere,  the  hydrochloric  acid  is 
often  deficient  among  pulmonary  invalids,  suggesting  in  many  instances 
the  expediency  of  employing  this  remedy.  It  is  inexpedient  to  resume  at 
once  efforts  toward  superalimentation,  raw  eggs  and  milk  between  meals 
being  ingested  but  sparingly.  Disturbances  of  this  nature,  though 
prone  to  recur  from  time  to  time,  yield  quickly  to  simple  treatment. 

Chronic  gastric  indigestion,  characterized  by  confirmed  anorexia, 
distress  and  pain  after  eating,  pyrosis,  nausea  and  vomiting,  and  even 
localized  tenderness,  is  far  more  obstinate  in  its  response  to  therapeutic 
management.  This  grouping  of  symptoms,  as  previously  stated,  may 
be  dependent  upon  structural  abnormality  of  the  stomach  or  upon  func- 
tional disturbances  incident  to  profound  psychoneurosis.  The  organic 
condition  may  be  that  of  chronic  catarrh  with  atrophy  of  the  mucosa, 
muscular  atony,  and  dilatation,  with  not  infrequently  enteroptosis  and 
associated  change  in  other  abdominal  organs.  It  is  sometimes  with  the 
utmost  difficulty  that  the  causative  conditions  may  be  differentiated, 
although  in  general  the  means  for  distinguishing  between  the  purely 
organic  and  functional  disorders  are  sufficiently  clear  to  admit  of  intelli- 
gent therapeusis. 

The  structural  changes  may  be  accompanied  by  cardialgia,  which 
is  often  acute.  There  may  be  redness  of  the  tip  and  margin  of  the 
tongue.  Eructation  of  gas  is  an  annoying  symptom,  which  is  sometimes 
intensified  by  the  regurgitation  of  bitter  or  sour  fluids.  Hydrochloric 
acid  is  usually  diminished  to  a  considerable  degree,  though  other  acids 
are  often  present.  The  treatment  of  the  purely  catarrhal  type  should 
consist  primarily  of  the  temporary  enforcement  of  a  rigid  milk  diet. 
The  milk  may  be  diluted,  if  necessary,  with  Apollinaris,  Vichy,  or  other 
effervescent  waters.  It  is  sometimes  important  that  it  be  peptonized 
until  the  patient  is  able  to  bear  solid  food.  At  this  time  it  is  essential 
that  mastication  should  be  thorough,  and  the  patient  compelled  to  devote 
an  unusually  long  time  to  the  ingestion  of  food.  Potatoes  and  other 
starchy  vegetables  should  be  forbidden,  together  with  fats,  sweets, 
pastry,  and  hot  bread.  Certain  fruits  are  often  injurious  for  some 
people,  restriction  in  this  respect  being  a  matter  of  individual  application. 
In  cases  exhibiting  hypochlorhydria,  dilute  hydrochloric  acid  should  be 
given  freely,  together  with  pepsin  and  other  digestive  ferments.  Bis- 
muth preparations  with  sodium  bicarbonate  may  be  administered, 
while  strychnin  or  nux  vomica  are  of  some  value  in  promoting  the  appe- 
tite. In  obstinate  cases  daily  irrigation  of  the  stomach  in  the  early 
morning  with  a  .3  per  cent,  solution  of  sodium  bicarbonate  or  of  boric  acid 
is  of  decided  advantage.  Some  patients  are  able  to  practise  autolavage 
with  signal  benefit,  without  the  use  of  the  stomach-tube.     Those  who 


706  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

can  easily  bring  about  emesis  should  be  instructed  to  drink  a  quart  of 
hot  normal  salt  solution  or  boric-acid  solution  about  an  hour  before 
breakfast.  If  regurgitated  without  difficulty,  this  method  is  highly 
efficacious.  Good  residts  are  often  obtained  by  repeating  the  lavage 
late  in  the  evening.  Washing  of  the  stomach  is  particularly  indicated 
in  cases  of  mucous  gastritis,  dilatation  of  the  stomach,  and  atony  of  its 
walls.  When  this  condition  exists,  fluids  should  be  somewhat  restricted, 
the  solid  food  given  in  small  quantities  and  at  frequent  intervals,  scraped 
beef  and  tender  meats  being  especially  well  borne.  In  the  event  of 
pronounced  enteroptosis,  support  for  the  abdominal  organs  should  be 
provided  by  a  belt  or  by  the  application  of  adhesive  straps. 

The  functional  neuroses  may  also  be  attended  by  violent  eructation 
of  gas,  vomiting,  partial  regurgitation  of  food,  and  gastric  distress  or 
distention  after  eating.  The  appetite  is  not  invariably  poor,  nor  is 
aversion  to  food  continuous,  fickleness  of  appetite  often  being  a  striking 
characteristic.  An  important  feature  is  the  accentuation  of  pain  and 
belching  when  the  stomach  is  empty,  rather  than  immediately  after 
the  ingestion  of  food.  The  symptoms  referable  to  the  dyspepsia  some- 
times completely  overshadow  the  manifestations  of  tuberculous  infec- 
tion. As  the  clinical  symptoms  are  often  extremely  complex,  represent- 
ing a  great  variety  of  neurotic  disturbances,  it  is  obviously  irrational  to 
attempt  to  treat  patients  of  this  class  along  purely  symptomatic  lines. 
Gastric  analyses  are  of  importance  largely  by  reason  of  their  moral  effect. 
The  same  is  true  of  a  strictly  regulated  dietary,  which,  for  psychic 
reasons,  should  not  be  enforced  for  prolonged  periods. 

The  underlying  principles  of  treatment  should  be  those  of  suggestion, 
rest,  fairly  generous  alimentation,  and  detailed  supervision  of  the  mode 
of  life.  Upon  the  intelligent  ai^plication  of  these  features  will  depend 
ultimate  success,  far  more  than  upon  the  perfunctory  selection  of  diet 
with  reference  to  alluring  symptomatic  indications,  a  study  of  the  stools 
or  of  the  stomach-contents. 

Considerable  difficulty  is  usually  experienced  in  overcoming  the 
prejudices  and  preconceived  notions  of  patients,  who  protest  their  utter 
inability  to  digest  certain  articles  of  food.  It  is  sometimes  advisable 
to  begin  with  small  quantities  of  such  easily  iligested  fooils  as  milk, 
broths,  eggs,  oysters,  squab,  chicken,  and  tender  meats.  Starches 
should  be  given  but  sparingly,  but  fats  may  be  administered  in  fairly 
moderate  amounts.  Among  chronic  dyspeptics  encouragement  and 
reassurance  should  be  freely  extended,  for  much  depends  upon  the 

iblishment  of  renewed  hope,  and  an  increasing  confidence  in  their 
tive  powers.  Food  should  be  gi\'en  between  meals,  in  order  that 
the  stomach  may  at  no  time  become  perfectly  empty. 

The  clinical  judgment  may  be  taxed  in  deciding  between  the  relative 
advantages  to  be  derived  in  individual  cases,  from  exercise  or  complete 
rest.  In  general  a  preliminary  recourse  to  a  modified  rest  treatment, 
with  isolation  and  competent  nursing,  is  peculiarly  efficacious,  but  in 
some  cases  the  indications  point  to  diversion,  recreation,  and  carefully 
adjusted  physical  exercise.  It  is  absolutely  essential  that  this,  if  per- 
mitted at  all,  should  be  unattended  by  fatigue,  lest  the  functional 
disturbances  become  aggravated  to  a  considerable  extent.  It  will  be 
seen  that  the  treatment  of  this  form  of  chronic  dyspepsia,  so  common 
among  neurotic  consumptives,  is  based  upon  the  treatment  of  the  indi- 
vidual, rather  than  of  the  stomach.     In  addition  to  change  of  scene. 


TREATMENT    OF    SPECIAL    SYMPTOMS  707 

environment,  method  of  living,  and  judicious  modification  of  diet,  it  is 
often  important  to  administer  certam  medicines  as  aids  to  digestion, 
as  well  as  for  their  general  effect.  Nux  vomica  and  strychnin  are  of 
considerable  value,  as  are  alkaline  remedies  in  large  doses  in  the  form 
of  magnesia  or  sodium  bicarbonate.  Preparations  of  bismuth  may  be 
indicated,  as  in  catarrhal  conditions  of  the  stomach  or  intestine.  The 
various  bitter  tonics  are  of  some  efficacy  in  a  few  cases.  For  severe 
pain  anodyne  remecUes  are  sometimes  appropriate,  but  should  not  be 
administered  save  in  exceptional  instances.  In  some  cases  nausea  is 
controlled  by  small  doses  of  ingiuvin.  If  the  general  nervous  disturb- 
ance is  pronounced,  excellent  results  may  be  obtained  from  the  admin- 
istration of  the  aqueous  extract  of  opium,  in  association  with  cannabis 
indica.  The  combination  which  I  have  used  for  years  in  innumerable 
instances  with  exceedingly  satisfactory  results  is  strychnin,  -^  grain, 
salol,  5  grains,  aqueous  extract  of  opium,  yV  grain,  extract  of  cannabis 
indica,  yV  grain,  aloin,  4^  grain,  after  each  meal.  In  no  case  has  there 
been  observed  any  untoward  effect  of  the  opiate,  or  a  tendency  toward 
habituation.  Upon  the  contrary,  with  the  control  of  general  nervous 
manifestations,  digestion,  as  a  rule,  is  improved,  mental  excitability 
diminished,  and  insomnia  relieved.  In  view  of  the  preponderance  \)f 
nervous  symptoms  in  a  large  proportion  of  cases,  and  the  difficulty  of 
successful  management  on  account  of  these  neurotic  disturbances,  it  is 
my  firm  conviction  that  the  employment  of.  the  above-mentioned  com- 
bination in  capsule  for  such  patients  is  of  inestimable  value. 

Constipation,  which  is  often  present  at  any  stage  of  pulmonary  tuber- 
culosis, may  be  favoraljly  influenced  by  colon  massage.  As  this  symp- 
tom is  exhibited  more  frequently  in  incipient  cases,  judicious  exercise 
is  permissible  for  a  large  number  of  patients,  combined  with  the  ingestion 
of  raw  fruits  and  coarse  vegetables.  Regularity  of  bowel  evacuation 
should  be  insisted  upon  with  the  utmost  strictness.  Copious  quantities 
of  hot  water  should  be  taken  an  hour  before  breakfast,  which,  if  insuf- 
ficient, may  be  reinforced  by  the  addition  of  sodium  phosphate  or  other 
alkalis.  For  occa.sional  use  small  quantities  of  Hunyadi  water  often 
suffice  if  taken  immediately  upon  arising.  Sweet-oil  enemata  are  some- 
times of  advantage,  together  with  preparations  of  cascara  by  mouth. 

The  treatment  of  diarrhea,  which  may  be  of  catavi-hal,  tulipi'culous, 
or  amyloid  origin,  is  especially  important.  Recent  fliiiical  invcstiiintion 
has  shown  that  tubercle  bacilli  are  present  in  the  U'rr>  iiinrc  cltcn  than 
has  been  supposed.  Rosenberger  has  found  bacilli  in  tliu  fi'tul  cli^^charge 
of  a  number  of  individuals  who  were  not  suspected  to  be  subjects  of 
tuberculous  infection.  In  a  large  proportion  of  these  cases  the  autopsy 
finchngs  disclosed  tubercle  deposit  in  some  portion  of  the  body. 

The  nature  of  the  treatment  is  not  necessarily  dependent  upon  a  deter- 
mination of  the  fundamental  character  of  the  diarrhea,  all  three  varieties 
demanding  practically  the  observation  of  the  same  general  measures. 
The  diet  should  be  restricted  almost  entirely  to  milk,  soup,  and  albumi- 
nous foods.  Lean  meats,  eggs,  fish,  and  oysters  may  be  given  freely, 
but  no  vegetables,  fruits,  or  pastry  should  be  allowed.  It  is  sometimes 
necessary  to  insist  upon  protracted  confinement  in  bed  and  an  exclusive 
diet  of  boiled  milk.  It  is  excellent  practice  to  empty  the  bowels  at  inter- 
vals with  calomel  in  divided  amounts,  or  with  sweeping  doses  of  castor 
oil,  following  which  there  is  not  uncommonly  secured  a  temporary 
respite  from  the  annoying  diarrhea.     Among  the  intestinal  astringents 


708  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

of  considerable  value  may  be  mentioned  the  salicylate  and  subgallate 
of  bismuth,  tannigen,  and  tannalbin.  Sixty  to  eighty  grains  of  salicylate 
of  bismuth  should  be  given  daily,  while  the  subgallate  may  be  adminis- 
tered in  still  larger  amounts.  Thirtj'  to  forty  grains  of  tannigen  may  be 
given  each  day,  supplementary  to  either  the  salicylate  or  subgallate  of 
bismuth.  In  very  obstinate  cases  recourse  may  be  taken  to  powdered 
opium  and  subacetate  of  lead,  in  doses  of  J  grain  and  one  grain  respect- 
ively. Enemata  of  starch,  with  deodorized  tincture  of  opium,  may  be 
occasionally  employed,  together  with  solutions  of  silver  nitrate.  In 
the  event  of  intestinal  flatulence  resulting  from  excessive  fermentation, 
antiseptics  are  of  more  importance  than  astringents.  A  most  excellent 
remedy  for  this  purpose  is  the  beta-naphthol  bismuth,  given  in  seven- 
grain  capsules  two  hours  after  eating.  Creasote  is  often  of  undoubted 
efficacy  in  small  doses,  its  effect  being  somewhat  enhanced  by  the  addi- 
tion of  ^  grain  of  menthol. 

Mucous  colitis  is  not  especially  infrequent  among  pulmonary 
invalids,  particularly  of  the  neurotic  type.  Paroxysmal  attacks  of 
pain  and  tenderness  in  the  abdomen,  with  the  passage  of  mucous  shreds 
or  strings,  may  be  associated  with  periods  of  excessive  mental  worry 
or  excitement.  The  treatment  should  be  directed  essentially  toward 
the  management  of  the  general  condition,  with  dietary  precautions, 
although  high  irrigation  of  the  colon  with  normal  salt  solution  is  some- 
times attended  by  satisfactory  results.  Only  such  food  should  be  per- 
mitted as  is  easy  of  digestion.  Meats  may  he  given  freely,  but  green 
vegetables,  fats,  and  starches  should  be  interdicted.  The  treatment  of 
intestinal  tuberculosis  has  been  described  under  Complications. 

Instances  of  acute  intestinal  toxemia  also  are  not  infrequent  among 
phthisical  patients.  The  attacks  are  invariably  of  sudden  onset, 
characterized  by  chill,  headache,  and  often  severe  pain  in  the  back  and 
limbs.  With  the  history  of  constipation  the  tongue  is  often  heavily 
coated,  the  breath  offensive,  and  the  taste  of  the  mouth  extremely 
unpleasant.  Without  other  symptoms  directly  refera!)le  to  the  gastro- 
intestinal tract,  the  temperature  may  range  as  high  as  103°  F.,  but  some- 
times does  not  exceed  101°  F.  The  patient,  as  a  rule,  is  completely 
prostrated,  and  the  general  clinical  manifestations  are  those  of  a  severe 
mixed  infection  of  some  kind.  There  may  be  tenderness  in  the  alidomen, 
but  this  is  not  present  in  all  cases.  Occasionally  small  hard  papules 
appear  on  the  hands,  arms,  or  body,  and  itch  intensely,  suggesting  the 
gastro-intestinal  tract  as  the  seat  of  the  trouble.  The  condition  is 
differentiated  from  influenza  by  the  absence  of  cough  or  catarrhal  symp- 
toms in  the  upper  air-passages.  Tonsillitis  is  excluded  by  in.spection 
of  the  throat,  and  pneumonia  in  most  instances  by  physical  examination 
of  the  chest.  The  possibility  of  tuberculous  meningitis  may  be  elimin- 
ated only  after  careful  ohservation  of  the  case.  The  initial  therapeutic 
indications  consist  of  immediate  purgation  with  large  doses  of  calomel, 
followed  by  magnesium  sulphate.  After  the  bowels  have  been  thor- 
ouglily  evacuated,  high  enemata  of  normal  salt  solution  should  be  freely 
administered  and  water  given  in  large  amounts  by  the  mouth,  with 
diuretin  or  potassium  citrate  to  stimulate  the  kidneys.  Food,  of  course, 
should  be  restricted  during  the  acute  stage,  the  chief  efforts  at  treatment 
being  directed  toward  evacuation  of  the  bowels,  gastro-intestinal  rest, 
dilution  and  elimination  of  the  toxins. 


TEKATMENT    OF    SPECIAL    SYMPTOMS  709 


NIGHT-SWEATS 

Attention  has  been  called  to  the  intimate  relation  between  night- 
sweats  and  fever,  both  symptoms  being  characteristic  manifestations 
of  mixed  infection.  In  such  cases  the  perspiration  accompanies  the 
fall  of  temperature  in  the  early  morning  hours.  Night-sweats,  however, 
may  be  observed  without  appreciable  temperature  elevation,  and,  per 
contra,  may  not  accompany  the  fever  of  sepsis.  Despite  the  inconstancy 
of  association  with  fever  and  other  subjective  symptoms  referable  to 
mixed  infection,  it  is  probable  that  in  all  instances  night-sweats  are 
influenced  to  some  extent  by  the  effect  of  toxemia  upon  the  vasomotor 
system.  When  sweating  occurs  as  an  incident  of  elevated  temperatures, 
it  is  rational,  if  not  obligatory,  to  concentrate  therapeutic  efforts  for 
the  time  being,  upon  the  reduction  of  fever  in  the  manner  elsewhere 
described.  It  is  not  always  true,  however,  that  disappearance  of  the 
night-sweats  will  follow  a  subsidence  of  the  fever.  Thus  measures  are 
indicated  for  the  relief  of  the  night-sweats,  whether  or  not  fever  is 
present.  For  this  purpo.se  hygienic  measures  are  of  especial  importance. 
Generally  speaking,  the  tendency  to  night-sweats  will  diminish  with  the 
more  complete  elaboration  of  a  system  of  outdoor  life.  In  addition  to 
the  constant  supply  of  fresh  air  and  perfect  rest  in  the  recumbent  posi- 
tion, it  will  be  found  that  dietetic  and  hydropathic  methods  often  suffice 
to  cause  the  disappearance  of  night-sweats  without  recourse  to  drug 
therapy.  The  bed-covering  should  be  light  and  of  woolen  material, 
to  the  entire  exclusion  of  comforters,  quilts,  or  heavy  spreads.  Gener- 
ous alimentation  with  regulation  of  the  digestion  is  fundamentally 
important.  If  the  temperature  is  not  materially  elevated  in  the  latter 
part  of  the  day,  the  patient  should  partake  of  a  hearty  evening  meal, 
which  may  be  followed  by  light  nourishment  at  bedtime.  Two  or  three 
teaspoonfuls  of  brandy  upon  retiring  may  be  administered  with  advan- 
tage. The  body  should  be  sponged  with  dilute  alcohol  or  some  acidu- 
lated preparation,  in  the  latter  part  of  the  afternoon,  and  again  in  the 
late  evening.  Vinegar  or  dilute  acetic  acid  may  be  used  for  this  pur- 
pose. Quinin  dissolved  in  alcohol  is  sometimes  employed  in  the  pro- 
portion of  one  dram  to  the  pint.  In  my  own  experience  excellent  results 
have  attended  the  use  of  chloral  hydrate  dissolved  in  brandy  and 
water,  2  drams  being  added  to  4  ounces  each  of  brandy  and  water. 
Sponging  the  surface  of  the  body  twice  daily  with  these  solutions,  which 
are  allowed  to  evaporate  upon  the  skin,  often  mitigates  the  severity  of 
the  night-sweats,  if  not  affording  complete  relief.  In  obstinate  cases 
medicinal  measures  are  indicated  from  time  to  time.  Camphoric  acid 
has  frequently  been  successful  in  doses  of  15  grains  two  or  three  times 
a  day,  preferably  after  the  midday  and  evening  meals.  In  my  experi- 
ence this  method  of  administration  has  been  preferable  to  the  employ- 
ment of  a  large  dose  at  bedtime.  Picrotoxin,  in  do.ses  of  ^wo  to  ?V  oi  a 
grain,  and  agaricin,  -^  to  y'j  of  a  grain,  are  recommended.  The  latter 
should  be  given  not  less  than  six  or  eight  hours  before  the  time  of  the 
expected  sweat.  If  all  other  measures  are  found  of  no  avail,  atropin,  in 
doses  of  Ywu  to  eV  of  a  grain,  may  be  given  at  bedtime,  though  recourse 
to  this  drug  should  be  deferred  as  long  as  possible  on  account  of  its  dis- 
turbing action  upon  the  digestive  functions. 


PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 


INSOMNIA 

Sleeplessness  may  result  from  cough,  physical  discomfort,  digestive 
disturbances,  night-sweats,  unpleasant  dreams,  general  restlessness,  and 
nervous  excitability.  Any  comprehensive  sj-stem  of  management 
must  be  based  upon  an  accurate  recognition  of  the  predisposing  causes, 
attention  to  cough,  night-sweats,  and  digestive  disorders  being  suggested 
as  essential  prerequisites  for  undisturbed  sleep. 

The  bed  should  be  comfortable,  the  clothing  neither  too  light  nor 
too  heavy,  and  the  general  en\ironment  suited  to  the  needs  of  the 
patient.  It  is  unwise  to  permit  indulgence  in  a  hearty  meal  shortly 
before  retiring  for  the  night.  Mental  perturbation  also  should  be 
scrupulously  avoided,  particularly  in  the  latter  part  of  the  day.  Mental 
suggestion,  if  practised  intelligently  and  per.sistently,  may  accomplish 
much  in  the  control  of  insomnia.  Hot  drinks  at  bedtime,  particularly 
milk  or  malted  milk,  may  increase  the  tendency  to  sleep,  while  a  small 
bottle  of  ale  is  of  some  service  provided  the  digestion  will  permit.  A 
hot  mustard  foot-bath  in  the  latter  part  of  the  evening  is  often  advan- 
tageous, as  is  cold  sponging  of  the  entire  body.  I  have  frequently 
found  massage  at  bedtime  to  be  of  signal  benefit  in  promoting  sleep 
which,  under  other  circumstances,  seemed  almost  impossible  of  attain- 
ment. Hypnotics  should  be  given  only  in  e.xtreme  cases,  and  then  but 
for  brief  periods  of  time.  In  such  ca.ses  it  has  been  my  practice  to 
administer  an  initial  dose  of  from  10  to  15  grains  of  trional  or  veronal 
in  hot  milk,  and,  if  possible,  induce  profound  sleep  for  a  single  night. 
Upon  the  following  evening  not  over  half  the  dose  is  administered,  and 
even  less  upon  the  third.  Upon  the  several  ensuing  nights  the  milk  is 
administered  alone,  without  the  knowledge  of  the  patient.  When 
occasion  requires,  small  doses  of  the  hypnotic  are  renewed  from  time  to 
time,  the  object  being  to  secure  the  greatest  amount  of  sleep  with  a 
minimum  use  of  the  drug.  Opiates  should  not  be  employed  for  this 
purpose  under  any  circumstances. 

CARDIAC  WEAKNESS 

It  has  been  emphasized,  in  preceding  pages,  that  rest,  subject  to 
mollification  according  to  the  requirements  of  the  individual,  is  an 
essential  feature  of  modern  therapeutic  management.  AbsoltUe  rest 
in  bed  is  demanded  for  patients  exhibiting  manifestations  of  cardiac 
weakness.  It  goes  without  saying  that  tachycardia,  palpitation,  breath- 
lessness,  exhaustion,  edema  of  the  extremities,  and  dizziness  of  cardiac 
origin,  permit  of  no  deviation  from  this  procedure.  By  rest  is  not 
meant  simple  physical  inertia,  but  also  a  complete  avoidance  of  mental 
excitement.  Worry,  agitation,  and  the  strain  of  maintaining  a  weari- 
some conversation  are  as  much  to  be  prohibited,  as  indulgence  in  bodily 
exercise.  The  various  symptoms  of  heart  weakness  are  frequently 
traced  to  the  existence  of  pronounced  neurasthenic  conditions,  which 
in  themselves  are  influenced  for  good  by  enforced  repo.se.  The  cardiac 
manifestations  oltcn  improve  commensuratcli/  with  gain  in  the  general 
strength,  and  in  the  more  stable  equilibrium  of  the  nervous  system. 
Digitalis  and  strophanthus  have  been  found  to  be  of  little  value.  In 
most  cases  strychnin  is  the  remedy  par  excellence,  and  in  appropriate 
conditions  may  be  associated  with  nitroglycerin.     Camphor  has  been 


TREATMENT  OF  PULMONARY  HEMORRHAGE  711 

used  to  some  extent  with  quite  successful  results.  Ten  to  twenty 
minims  of  a  sterilized  10  per  cent,  solution  in  olive  oil  may  be  admin- 
istered for  several  weeks  without  especial  inconvenience  to  the  patient, 
and  often  with  evidence  of  signal  improvement.  Aromatic  spirits  of 
ammonia,  and  alcohol,  in  the  form  of  whisky,  brandy,  or  champagne, 
are  especially  desirable  if  the  heart  weakness  is  accompanied  by  fall  of 
temperature.  The  application  of  an  ice-bag  is  sometimes  of  service, 
particularly  in  cases  of  pronounced  tachycardia.  Light  massage  with 
carefull}^  adjusted  resistance  exercises  are  occasionally  permissible,  pro- 
vided, of  course,  the  nature  of  the  cardiac  difficulty  is  suited  to  the 
application  of  these  measures.  Obviously,  the  latter  form  of  therapeusis 
for  the  heart,  though  eminently  satisfactory  to  the  requirements  of  cer- 
tain individuals  exhibiting  a  coincident  slight  tuberculous  infection,  is 
entirely  inappropriate  for  advanced  cases. 


CHAPTER   XCVII 
TREATMENT  OF  PULMONARY  HEMORRHAGE 

GENERAL  CONSIDERATIONS 

The  treatment  of  this  condition  is  uniquely  different  from  that  of 
hemorrhage  occurring  in  other  parts  of  the  body,  by  virtue  of  the  fact 
that  management  is  restricted  to  palliative  and  expectant  measures, 
to  the  entire  exclusion  of  surgical  procedures.  In  sharp  contrast  to  the 
prompt  exposure  and  ligation  of  bleeding  points  within  the  abdomen, 
loss  of  blood  from  ruptured  vessels  in  the  thorax  must  be  controlled, 
if  at  all,  through  supplementary  aid  to  the  natural  agencies  productive 
of  spontaneous  arrest.  Fortunately,  the  undisturbed  forces  of  nature 
are  much  more  likely  to  effect  a  cessation  of  hemorrhage  from  the  lungs, 
than  from  abdominal  organs,  the  contraction  of  vessels  and  thrombus 
formation  often  taking  place  before  exsanguination  is  complete  or  col- 
lapse profound.  The  inherent  tendency  of  the  organism  to  effect  a 
spontaneous  control  through  reduction  of  volume,  increased  coagula- 
bility, and  diminished  rapiditi/  of  blood-flow  undoulitedly  explains  the 
surprising  number  of  recoveries  in  the  presence  of  divergent  and  some- 
times irrational  methods  of  practice. 

The  management  of  no  other  clinical  manifestation  calls  for  an 
equal  display  of  judgment  and  acumen  on  the  part  of  the  physician,  and 
demands  such  implicit  obedience  from  the  patient  and  attendants.  The 
conception  of  treatment  should  be  preeminently  practical,  rather  than 
theoretic,  and,  in  fact,  may  become  almost  intuitive.  No  attempt 
should  be  made  to  base  the  nature  of  therapeutic  management  in  differ- 
ent cases  upon  a  precise  determination  of  the  possible  causes.  Such 
differentiation  is  quite  impracticable,  and  bears  no  actual  relation  to 
the  manner  of  treatment.  Not  only  is  it  of  but  slight  importance  to 
distinguish  between  the  various  anatomic  conditions  responsible  for  the 
production  of  hemorrhage,  but  in  like  manner  the  recognition  of  the 
extent  and  character  of  gross  pathologic  change  fails  to  modify  appre- 


712  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

ciably  the  indications  for  rational  therapeusis.  It  is  frequently  impossi- 
ble to  secure  perfect  familiarity  with  the  phj'sical  condition,  on  account  of 
the  inexpediency  of  conducting  a  thorough  examination  until  the  likeli- 
hood of  recurrence  has  subsided.  While  the  information  concerning  the 
existence  of  pulmonary  cavities,  areas  of  consolidation,  or  of  fibroid 
induration  does  not  materially  influence  the  character  of  therapeutic 
management,  certain  features  of  pathologic  import  are  possessed  of 
great  significance,  notably  the  presence  of  mixed  infection,  chronic 
nephritis,  and  the  development  of  septic  pneumonia.  The  vital  con- 
sideration is  the  modification  of  treat  incut  according  to  an  intelligent 
interpretation  of  the  clinical  maniji stdtions.  rather  than  from  a  groping 
assumption  as  to  the  exact  causatirt  nijlmnccs.  Clinical  features  of 
great  moment  in  association  with  hemorrhage,  are  elevation  of  tem- 
perature, cyanosis,  heightened  blood-pressure,  the  acceleration  or  feeble- 
ness of  the  pulse,  dyspnea,  and  collapse. 

It  is  of  the  utmost  importance  to  appreciate  the  rarying  indications 
for  treatment  which  are  presented  by  different  people,  and  often  from 
hour  to  hour  by  the  same  patient.  In  every  case  of  pulmonary  hemor- 
rhage the  management  should  be  determined  to  a  large  extent,  according 
to  the  peculiar  clinical  manifestations  exhibited  by  the  individual.  Under 
no  other  circumstances  are  the  exercise  of  vigilant  observation,  atten- 
tion to  detail,  and  a  critical  study  of  cause  and  effect  more  necessarj-. 
No  medical  practice  can  be  productive  of  more  harmful  results  than  the 
employment  of  routine  methods  in  the  treatment  of  hemoptysis,  to  the 
exclusion  of  a  wise  discrimination  regarding  drug  therapy  and  hygienic 
details.  Numerous  remedies  without  regard  to  their  physiologic  action, 
or  their  suitability  for  special  cases  are  occasionaUy  administered  in  a 
spirit  of  utter  empiricism.  In  other  instances,  purely  theoretic  notions 
are  elaborated  as  to  the  effect  of  certain  drugs  upon  the  general  and 
pulmonary  circulation,  while  erroneous  conceptions  are  not  infrequently 
entertained  regarding  the  influence  of  external  hygienic  measures.  Thus 
a  disproportionate  value  may  be  attached  to  a  few  time-honored  rem- 
edies, with  neglect  to  utilize  important  features  of  regime.  The  admin- 
istration of  medicinal  preparations,  with  a  few  notable  exceptions,  is 
attended  by  directly  harmful  results,  while  detailed  supervision  of  the 
patient  and  surroundings  is  remarkably  efficacious.  In  disparaging  the 
employment  of  general  drug  therapy  for  pulmonary  hemorrhages,  it  is 
important  not  to  include  one  or  two  remedies  which  exert  a  profound 
influence  upon  the  entire  system,  with  indirect  effects  upon  the  pulmo- 
nary circulation.  As  will  be  seen  presently,  their  value  in  judiciously 
proportioned  doses  is  exceedingly  great. 

THERAPEUTIC  MANAGEMENT 

The  treatment  of  pulmoiuirv  hemorrhage  has  been  thought  to  be 
capable  of  division  into  palliative  and  preventive  efforts.  It  appears 
quite  unnecessar}',  however,  to  make  this  distinction  save  in  extreme 
cases,  as  there  is  no  essential  difference  characterizing  the  attempt  to 
arrest  bleeding,  and  the  endeavor  to  pre^•ent  immediate  recurrence. 
Hemorrhages  often  take  place  in  .serial  form,  one  following  another 
either  in  comparatively  quick  succession  or  after  the  lapse  of  a  few  hours. 
Occasionally  one  or  two  days  may  intervene  between  these  distressing 
experiences.    In  view  of  the  tendency  to  prompt  recurrence  and  the  neces- 


TREATMENT  OF  PULMONARY  HEMORRHAGE  713 

sity  of  continuous  rigid  precautions,  the  palliative  treatment  naturally 
resolves  itself  into  one  of  prevention.  The  physician  is  rarely  present 
at  the  time  of  the  initial  hemorrhage,  while  the  subsequent  recurrences 
form  but  an  incident  in  the  general  scheme  of  systematic  management. 
In  view  of  the  many  degrees  of  severity,  the  manifold  phases  exhibited, 
and  the  variety  of  therapeutic  indications  in  different  instances,  it  is 
manifestly  impossible  to  recite  in  detail  methods  of  treatment  properly 
applicable  to  hypothetic  cases.  Broad  generalizing  statements,  how- 
ever, may  be  made  from  which  to  formulate  principles  capable  of  indi- 
vidual application. 

Important  features  of  treatment  relate — (1)  To  the  initial  directing 
influence  of  the  physician;  (2)  attention  to  vitally  important  details 
of  management  and  environment;  (3)  rational  employment  of  selected 
drugs;  (4)  application  of  special  methods. 

INFLUENCE   OF   THE  PHYSICIAN 

Experience  has  shown  that  in  the  very  beginning  of  treatment  a 
firm,  controlling  influence  upon  the  mental  attitude  of  the  patient  is 
of  incalculable  value.  Nothing  is  more  subservient  of  good  results 
than  the  possession  of  a  calm,  hopeful  frame  of  mind,  combined  with 
an  earnest  desire  for  obedient  cooperation.  Such  mental  status  is 
often  exceedingly  difficult  of  inculcation,  and  is  dependent  to  an  enor- 
mous extent,  upon  the  personal  influence  and  demeanor  of  the  medical 
attendant. 

Extraordinary  differences  are  exhibited  by  patients  in  the  men- 
tal effect  estabUshed  by  the  incidence  of  pulmonary  hemorrhage. 
Many  are  prone  to  regard  the  occurrence  as  of  trifling  significance,  and 
affect  a  seeming  indifference.  With  apparent  nonchalance  they  boast 
of  the  number  of  hemorrhages  experienced,  and,  strangely  enough, 
manifest  pride  in  their  previous  non-conformity  to  instructions.  To 
such  patients,  who  are  referring  continually  to  their  past  record,  it  is 
with  the  utmost  difficulty  that  there  may  be  conveyed  an  adequate 
appreciation  of  the  importance  of  the  condition,  and  the  necessity  of 
careful  supervision.  Not  infrequently  these  people,  doubting  either  the 
sincerity  or  the  soundness  of  their  medical  advice,  are  loath  to  accept 
the  statement,  that  recovery  from  an  astonishingly  large  number  of 
hemorrhages  affords  no  valid  excuse  for  ignoring  the  possible  gravity 
of  recurrences.  It  is  not  uncommon  in  health  resorts,  to  observe  among 
these  "old  timers"  great  reluctance  in  submitting  to  medical  super- 
vision. In  some  cases,  despite  the  onset  of  pulmonary  hemorrhage,  an 
active  out-of-door  existence  may  for  a  time  remain  uninterrupted  until 
the  patient  of  neces.sity  is  compelled  to  yield  final  obedience.  Occasion- 
ally, a  portion  of  the  responsibility  for  the  evil  results  must  be  assumed 
by  the  medical  adviser,  to  whose  laxity  and  carelessness  is  attril:)utal)le 
the  disastrous  delay.  Let  it  be  asserted  with  the  utmost  emphasis 
that  every  case  of  pulmonary  hemorrhage  should  be  regarded  as  of 
grave  import  until  its  complete  arrest,  prevention  of  recurrence,  and 
absence  of  .iequelse  have  been  determined  beyond  peradventure.  as  a 
result  of  continuous  observation.  No  matter  how  apparently  insig- 
nificant the  hemorrhage,  loss  of  blood  from  the  lungs  is  worthy  in  all 
instances  of  judicious  supervision.  Several  times  I  have  been  forced  to 
witness  the  development  of  septic  bronchopneumonia  and  death,  follow- 


714  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

ing  the  initial  expectoration  of  two  or  three  ounces  of  blood  by  indi- 
viduals refusing  to  yield  conformity  to  the  principles  of  rest  and  hygienic 
management.  I  recall  many  instances  of  sudden  death  from  severe  hem- 
orrhage as  a  result  of  bicycle-riding,  driving,  and  dancing,  despite  the 
warning  signals  displayed  by  slight  initiatory  hemoptyses.  Small  repeated 
hemorrhages,  though  not  in  themselves  necessary  elements  of  clanger, 
yet  if  persistently  ignored,  represent,  like  the  red  flag  waved  before  the 
approaching  train,  the  existence  of  possible  sources  of  destruction.  An 
appeal,  therefore,  is  made  for  at  least  the  tentative  enforcement  of  pre- 
cautionary measures  in  all  cases  of  hemoptysis,  even  if  the  loss  of  blood 
is  quite  inconsiderable.  Among  people  of  this  class,  in  order  to  secure 
implicit  obedience,  the  attitude  of  the  physician  should  often  be  that 
of  -peremptory  command,  indomitable  patience,  and  co7isummate  tact. 

The  effect  of  hemorrhage  upon  another  group  of  patients  is  quite 
the  reverse  of  the  preceding,  there  sometimes  being  produced  the  greatest 
possible  amount  of  consternation  and  dismay.  The  fears  of  the  invalid 
may  be  so  exaggerated  as  to  take  the  form  of  an  almost  hopeless  and 
unspeakable  terror.  This  unfortunate  mental  state  is  accentuated  in 
many  cases  by  the  excitability  of  relatives.  Under  such  circumstances 
prompt  and  emphatic  reassurance  not  only  represents  a  prime  obligation 
upon  the  mecUcal  attendant,  but  constitutes  as  well  a  most  important 
feature  of  treatment.  It  is  eminently  good  practice  to  calm  the  per- 
turbed feelings  and  restore  equanimity  of  temperament  as  quickly  and 
fully  as  possible.  A  judicious  endeavor  to  assuage  the  fears  of  the 
patient  is  usually  successful  in  inspiring  hope,  the  establishment  of 
confidence  often  minimizing  to  a  degree  the  likelihood  of  recurrence. 
It  is  impossible  to  overestimate  the  beneficial  effect  produced  by  the 
kindly  encouraging  words  of  the  physician  at  a  time  of  such  critical 
moment.  Optimistic  cheer  should  be  extended  no  less  in  the  midst  of 
desperate  conditions,  than  in  the  presence  of  smaller  hemorrhages. 
Physicians  who.  upon  words  of  encouragement,  ha\-e  noted  the  relieved 
countenance  of  the  invalid  in  place  of  an  overshadowing  expression  of 
fear  and  demoralization,  will  accord  hearty  support  to  the  wisdom  of 
ever-ready  reassurance  to  patients  of  this  class. 

REGARD   FOR    DETAIL 

Attention  to  infinite  detail  represents  a  feature  of  management  of  the 
very  greatest  importance.  It  should  be  remembered  that  hemorrhagic 
patients  are  extremely  susceptible  to  nervous  influences,  the  tendency 
to  bleed  being  aggravated  enormously  by  slight  annoyances  and  minor 
physical  indiscretions.  Thus  it  is  incumbent  upon  the  physician  to 
exercise  a  strict  supervisory  control  over  all  that  pertains  to  the  invalid 
and  the  environment. 

It  is  essential  that  no  person  should  be  allowed  in  the  sick-room 
besides  the  nur.se,  as  to  who.se  .selection  considerable  discrimination 
should  be  exercised.  In  addition  to  perfect  familiarity  with  similar 
conditions,  the  nurse  must  display  primarily  a  ready  adaptability  to  the 
individual  requirements,  in  order  that  the  sensibilities  of  the  patient 
be  not  disturbed  by  virtue  of  peculiar  idiosyncrasies.  Her  predomi- 
nant characteristics  should  be  cheerfulness  but  firmness  of  disposition, 
reticence  but  courage  at  times  of  emergency,  scrupulous  devotion  to 
detail,  and  vigilance  of  observation.     If  the  patient  is  consigned  to  the 


TREATMENT  OF  PULMONARY  HEMORRHAGE  715 

care  of  relatives,  a  painstaking  effort  should  be  made  in  the  selection 
and  instruction  of  the  attendant,  to  the  end  that  a  soothing  and  rest- 
ful influence  surround  the  invalid  at  all  times.  Conversation  in  the 
room  should  be  strictly  enjoined,  the  patient  being  addressed  only 
when  necessary  and  always  in  words  of  encouragement.  The  invalid 
should  not  be  permitted  to  reply  save  in  the  whispered  voice,  assent 
being  made  whenever  possible  by  a  mere  nod  of  the  head,  as  loud  talk- 
ing is  often  conducive  to  a  recurrence. 

The  room  should  be  kept  at  an  even,  cool  temperature,  with  an 
abundance  of  air,  but  without  exposure  of  the  patient  to  chrect  drafts. 
The  temperature  should  rarely  exceed  60°  F.  in  the  bed-chamber,  which 
should  be  isolated  as  much  as  practicable  from  other  portions  of  the 
house.  Frequent  opening  and  closing  of  windows  or  doors  should  be 
prohibited,  in  order  that  the  element  of  noise  be  eliminated  to  the  great- 
est possible  extent.  For  the  same  reason  the  jarring  of  tables,  moving 
of  beds,  or  rocking  of  chairs  should  be  restricted. 

The  patient  should  remain  at  all  times  in  the  recumbent  posi- 
tion, upon  a  moderately  hard  mattress,  with  the  head  but  slightly 
elevated.  In  exceptional  instances  the  head  and  shoulders  may  be 
raised  slightly,  this  being  justified  by  severe  dyspnea,  but  permittetl 
for  no  other  reason.  The  contention  is  made  by  some  clinicians  that 
the  semirecumbent  position  is  more  advantageous  on  account  of  the 
added  facilities  afforded  for  easy  expectoration.  With  the  invalid  in  the 
complete  recumbent  posture,  the  expectoration  may  be  received  into  a 
towel  or  piece  of  gauze  held  by  the  nurse,  with  the  head  of  the  patient 
turned  slightly  to  one  side.  Other  physicians  advise  placing  the  patient 
upon  the  affected  side,  in  order  to  prevent  the  return  passage  of  blood 
into  the  bronchi  of  the  sound  lung,  but  tlu'sc  conclusions  appear  more 
theoretic  than  practical.  As  a  rule,  invalids  aic  ;il  jjc  to  remain  squarely 
upon  the  back  for  prolonged  periods,  but  this  is  not  the  case  if  resting 
upon  either  side.  The  act  of  turning,  e\cu  with  the  assistance  of  the 
nurse,  is  often  sufficient  to  induce  cough,  jurclcraic  icspiration,  elevate 
blood-pressure,  excite  nervous  apprehension .  and  pioduce  hemorrhage. 
It  is  difficult  to  understand  why  regurgitation  of  lilood  into  the  bronchi 
of  the  sound  lung  is  more  to  be  feared  than  into  the  bronchial  tract  of 
the  affected  side.  In  fact,  it  would  seem  that  the  tendency  to  broncho- 
pneumonia might  be  increased  by  the  inspiration  of  blood  in  those 
bronchioles  exhibiting  previous  pathologic  change. 

A  cardinal  principle  of  management  should  be  the  absolute  main- 
tenance of  the  patient  in  a  fixed  position.  The  arms  should  remain 
in  a  comfortable  position  by  the  side,  at  no  time  being  raised  to  the 
head.  The  knees  should  not  be  elevated  save  during  the  use  of  the  bed- 
pan. The  bed-clothing  should  be  light  and  consist  merely  of  a  sheet 
and  one  or  two  blankets,  according  to  the  season.  The  food  should  be 
simple,  and  consist  entirely  of  cold  liquids  or  semiliquids  during  the 
period  of  greater  emergency.  Milk,  beef-juice,  gelatinous  ]iicp;ir:iti()ns, 
and  ice-cream  may  be  given,  provided  but  small  quantitii-  aic  ullowed 
at  a  time.  No  articles  of  diet  should  be  permitted  requiring  mast  icai  ion. 
It  is  unwise  to  administer  medicine  by  mouth,  for  fear  of  inducing  vomit- 
ing, with  the  attendant  strong  probability  of  exciting  recurring  hemor- 
rhages. No  remedy  save  an  occasional  cathartic  is  indicated  that  cannot 
be  administered  to  greater  advantage  hypodermatically,  by  inhalation, 
or  by  the  rectum.     In  taking  nourishment  the  head  should  not  be  raised 


716  PROPHYLAXIS,    GEXKRAL    AND    SPECIFIC    TREATMENT 

from  the  pillow,  the  food  being  given  by  the  nurse  either  with  a  spoon 
or  through  a  drinking  tube  or  cup.  Pieces  of  ice  to  be  held  in  the  mouth 
may  be  freely  given.  This  is  found  to  add  materially  to  the  comfort 
of  the  invalid,  to  relieve  dryness  of  the  buccal  mucous  membrane, 
to  lessen  the  likelihood  of  recurrence,  to  allay  cough,  and  control 
nausea. 

It  is  eminently  desirable  that  the  bowels  be  moved  once  daily,  although 
it  must  be  recognized  that  imminent  danger  of  hemorrhage  is  induced 
by  the  strain  incident  to  defecation.  Save  under  exceptional  circum- 
stances, particularly  the  development  of  renewed  hemorrhage,  failure 
to  secure  a  satisfactory  evacuation  of  the  bowels  once  in  twenty-four 
hours  constitutes  palpable  neglect.  Inattention  to  this  feature,  with  the 
development  of  fecal  impaction,  has  constituted  the  turning-point  in 
the  destinies  of  many  an  unfortunate  sufferer  from  pulmonary  hemor- 
rhage. The  function  of  defecation  often  I'epresents  one  of  the  most 
important  obstacles  in  the  path  of  the  bleeding  consumptive,  instances 
of  recurrence  during  or  immediately  following  the  performance  of  this 
act,  being  common  in  the  experience  of  all  phthisiotherapeutists.  The 
difficulties  are  intensified  to  a  very  great  extent  by  the  unavoidable 
administration  of  opiates. 

It  is  an  excellent  practice  to  produce  softening  of  the  rectal  con- 
tent by  the  injection  of  small  quantities  of  sweet  oil.  Two  ounces 
may  be  given  in  this  manner,  followed  in  two  hours  by  a  similar 
amount,  and  again  after  an  equal  lapse  of  time  by  an  enema  of  soap- 
suds and  water.  Comparatively  little  or  no  discomfort  is  experienced 
from  these  injections.  If  a  satisfactory  result  is  not  secured  by  this 
means,  a  safe  procedure  consists  of  the  injection  of  five  or  six  ounces 
of  the  compound  infusion  of  senna,  which  is  also  retained,  as  a  rule, 
without  difficulty.  If  repeated  every  hour  for  two  or  three  doses, 
thorough  evacuations  are  usually  secured.  In  the  e^■ent  of  obstinate 
constipation  and  abdominal  distention  high  enemata  are  found  to  be 
particularly  efficacious.  These  may  consist  of  two  ounces  each  of  a 
saturated  solution  of  magnesium  sulphate,  glycerin,  and  spirits  of  tur- 
pentine, diluted  with  six  ounces  of  normal  salt  solution.  With  some 
patients  recourse  must  be  taken  to  the  mouth  for  the  administration 
of  an  effective  laxative,  the  use  of  magnesium  citrate  or  other  alkaline 
preparations  often  being  followed  by  satisfactory  results.  In  obstinate 
cases  no  agent  is  so  thoroughly  and  blandly  efficient  in  producing  sweep- 
ing movements  of  the  bowels  as  a  large  dose  of  castor  oil.  The  natural 
repugnance  of  the  patient  is  entirely  overcome  by  administering  the  oil 
in  a  small  quantity  of  beer  or  slightly  flavored  effervescent  water,  but 
success  in  this  respect  depends  entirely  upon  the  technic  of  its  admin- 
istration. One  ounce  of  oil  should  be  "placed  in  a  wineglass.  The  beer 
or  the  effervescent  liquid  should  be  poured  into  a  drinking-glass,  and 
stirred,  if  necessary,  to  promote  foaming,  when  the  wineglass  containing 
the  oil,  should  be  in^■erted  over  and  poured  into  the  center  of  the  aer- 
ated liquid  without  touching  the  side  of  the  glass,  and  the  preparation 
swallowed  without  delay.  Thus  deprived  of  its  disagreeable  taste,  the 
oil  is  rarely,  if  ever,  productive  of  nausea. 

It  is,  of  course,  apparent  that  some  modification  of  stringent  detail 
in  the  management  of  pulmonary  hemorrhage  may  be  permitted  for 
less  urgent  conditions,  but,  in  general,  a  necessity  exists  for  the  obser- 
vance of  rigid  detailed  precautions.     For  the  purpose  of  illustration  the 


TREATMENT  OF  PULMONARY  HEMORRHAGE  717 

following  case,  which  has  recently  come  uilder  my  observation,  is  of 
interest.  The  patient  was  found  to  have  experienced  a  series  of  hemor- 
rhages during  a  period  of  three  weeks,  and  to  have  become  much 
exhausted,  more  or  less  exsanguinated,  having  an  embarrassed  respi- 
ration, feeble  pulse,  and  daily  elevation  of  temperature.  Inquiry 
elicited  the  fact  that  despite  perfectly  rational  medicinal  management, 
she  had  been  permitted  to  sit  up  in  bed  during  the  entire  period,  to 
receive  callers  daily,  to  engage  in  trying  conversation,  to  indulge  in 
hearty  meals,  and  to  reject  the  use  of  the  bed-pan.  No  more  striking 
commentary  is  needed  to  verify  the  assertion  that  the  importance  of 
detail  in  the  management  of  pulmonary  hemorrhage  is  not  always 
recognized  to  a  sufficient  extent. 

EXHIBITION  OF  DRUGS 

The  employment  of  drugs  for  pulmonary  hemorrhage  has  been  based, 
to  a  great  extent,  upon  their  supposed  influence  in  diminishing  the  volume 
of  blood  in  the  lungs,  increasing  its  coagulability,  or  in  reducing  arterial 
pressure  in  the  pulmonary  circulation.  Recent  experimental  research 
has  shown  that  views  previously  entertained  with  reference  to  the 
relation  of  the  systemic  to  the  pulmonary  blood-pressure,  have  been 
erroneous.  It  has  been  made  clear  that  constriction  of  the  peripheral 
vessels  is  attended  by  a  greater  influx  of  blood  in  the  pulmonary  artery, 
with  consequent  increase  of  pressure.  Thus  ergot  and  similar  remedies 
possessing  styptic  qualities  through  the  vasomotor  constriction  induced, 
must  exert  a  distinctly  unfavorable  influence  by  virtue  of  the  heightened 
pressure  in  the  pulmonary  artery  and  its  branches.  Even  were  such 
agents  known  to  produce  identical  effects  upon  the  pulmonary  and 
general  arterial  circulation,  it  is  extremely  doubtful  if  practical  good 
could  be  accomplished  in  an  attempt  to  reduce  the  volume  of  blood  in 
the  lung,  for  the  accompanying  pathologic  changes  are  often  of  such  a 
character  as  to  prevent  the  contraction  of  the  vessel  at  the  site  of  the 
hemorrhage.  All  remedies,  therefore,  calculated  to  reduce  volume  are 
not  only  worthless,  but  directly  harmful.  Digitalis  may  be  included  in 
this  list,  although  it  may  be  seriously  questioned  if,  in  doses  usually 
prescribed,  the  present  commercial  preparation,  as  adulterated,  can  exert 
any  influence  whatever.  At  all  events,  any  effect  produced  by  this 
agent,  in  the  vast  majority  of  hemorrhagic  cases,  must  be  delayed, 
cumulative,  and  disastrous. 

Wright  has  shown  that  the  coagulability  of  the  blood  is  increased 
by  the  exhibition  of  calcium  lactate  and  diminished  by  sodium  citrate. 
Clinical  experiments  have  been  conducted  in  the  hope  of  utilizing  the 
information  acquired  to  the  practical  benefit  of  invalids  suffering  from 
pulmonary  hemorrhage.  My  own  experience  with  calcium  lactate  in 
15-grain  closes,  and  calcium  chlorid  in  10-grain  doses,  has  not  been  such 
as  to  establish  their  clinical  value.  In  some  instances  vomiting  has 
promptly  ensued,  and  in  other  cases  mild  gastric  disturbances  not 
properly  attributable  to  other  causes.  Calcium  chlorid  given  by  rectum 
has  failed  to  yield  positive  assurance  of  its  remedial  efficiency.  Gelatin 
administered  hypodermatically  may  be  endowed  with  some  properties 
tending  to  increase  the  coagulability  of  the  blood,  but  its  administration 
in  this  manner  is  exceedingly  painful,  and  attended  with  the  possibility 
of  inducing  tetanus.     If  thus  employed,  the  greatest  caution  should  be 


/  Is  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC   TREATMENT 

observed  in  sterilizing  the  liquid  and  eliminating  commercial  impurities. 
The  following  method  of  preparation  is  reasonably  safe: 

Sterilized  salt  solution,  4  ounces;  best  white  gelatin,  1.2  ounces;  make  slightly 
alkaline  with  sodium  hydroxid,  1.2  drams.  Place  in  flask  with  glass  stopper  and 
sterilize  one-half  hour,  under  steam,  for  five  sucte.s.si\  p  days.  If  cloudy  from  alka- 
linization,  it  should  be  filtered  until  clear.  This  is  to  be  diluted  eight  times  to 
make  one  quart  for  subcutaneous  use. 

Gelatin  if  given  by  the  mouth,  can  do  no  harm  and  possibly  some 
good,  but  this  remains  subject  to  verification.  j\I\'  practice,  when 
using  it  in  this  manner,  is  to  give  not  less  than  one-third  ounce  of  com- 
mercial gelatin  daily,  but  this  large  amount  usually  becomes  repugnant 
to  the  patient  within  a  short  time. 

Efforts  to  diminish  arterial  pressure  in  the  pulmonary  circulation 
by  reducing  the  total  volume  of  blood  are  usually  irrational,  a  consider- 
able general  depletion  having  already  taken  place  as  a  result  of  the 
hemorrhage  itself.  Occasionally,  good  results  may  be  obtained  by 
moderate  venesection,  especially  when  the  initial  loss  of  blood  is  slight, 
fever  persistent,  small  hemorrhages  frequent,  and  blood-pressure  abnor- 
mally high.  In  general,  a  satisfactory  reduction  of  arterial  pressure 
may  be  secured  by  the  cautious  employment  of  amyl  nitrite,  nitro- 
glycerin, or  sodium  nitrite.  These  agents  produce  chlatation  of  the 
peripheral  arteries,  with  also  a  probable  reduction  of  pressure  in  the 
pulmonary  circulation.  It  has  been  claimed  by  some,  that  their  action 
upon  the  pulmonary  arteries  is  that  of  \-asoconstriction,  being  precisely 
the  i"everse  of  their  effect  upon  the  general  arterial  circulation.  Their 
clinical  value,  however,  seems  to  be  abundantly  established,  regardless 
of  theories  concerning  the  physiologic  action.  Amyl  nitrite  is  the  most 
prompt  in  its  salutary  effect,  but  its  influence  upon  the  circulation  is 
dissipated  within  a  short  time.  Its  employment  should  be  restricted 
to  the  actual  period  that  hemorrhage  is  taking  place,  when  it  may  be 
given  by  inhalation  in  doses  of  from  three  to  five  minims.  Similar  con- 
.stitutional  effects,  but  of  longer  duration,  may  be  instituted  by  the 
use  of  nitroglycerin  and  sodium  nitrite.  Under  the  exhibition  of  these 
agents  a  distinct  fall  in  general  arterial  pressure  is  usually  noted  upon 
palpation  of  the  pulse,  as  well  as  by  the  use  of  the  blood-pressure  appa- 
ratus. While  the  tendency  to  recurrence  is  undoubtedly  lessened  under* 
the  influence  of  nitroglycerin,  it  is  often  impossible  to  determine  with 
accuracy  the  limits  of  safe  and  justifiable  dosage.  Administered  in 
y^-grain  doses  every  three  or  four  hours  for  a  few  days  according  to 
apparent  indications,  it  is  admittedly  of  some  value.  Its  place,  how- 
ever, in  the  drug  armamentarium  of  the  physician  is  quite  subordinate 
to  that  of  one  or  two  other  remedies. 

By  far  the  most  important  medicinal  agent  in  the  treatment  of  pulmo- 
naiy  hemorrhage  is  morphin,  the  influence  of  which  is  directed  toward 
the  relief  of  cough,  the  calming,  as  a  rule,  of  nervous  cxcitnhilit)/.  and  the 
slowing  of  the  respiratiorrs.  There  is  also  an  apparent  effect  upon  the 
hemorrhage  itself.  No  other  drug  is  endowed  with  such  highly  beneficent 
power,  in  the  treatment  of  a  condition  often  frightful  beyond  description, 
and  always  distressing  to  a  degree.  The  measure  of  its  efficacy  is  entirely 
dependent  upon  the  intelligence  and  sagacity  of  the  physician  in  recog- 
nizing clearly  the  indications  for  size  and  frequency  of  dosage.  Of  all 
things,  there  should  not  be  permitted  any  adherence  to  conventionalism 
in  its  administration,  at  a  time  when  the  life  of  the  patient  is  so  greatly 


TREATMENT  OF  PULMONARY  HEMORRHAGE  719 

contingent  upon  a  judicious  conception  of  the  therapeutic  relation  of 
cause  and  effect.  It  is  vitally  important  that  the  patient  should  be 
kept  constantly  under  the  benign  influence  of  the  drug,  the  cough 
allayed  by  its  soothing  effect,  and  the  nervous  system  subdued  to  a 
state  of  peaceful  calm.  Sleep  is  often  profound  at  such  times,  the 
respirations  are  slow,  and  the  likelihood  of  hemorrhage  correspondingly 
diminished.  The  remedy  should  not  be  administered  in  stereotyped 
doses,  nor  at  long,  irregular  intervals. 

The  important  indications  pertaining  to  the  adjustment  of  dosage 
consist  of  the  degree  (if  restlessness,  the  frequency  and  severity  of 
cough,  the  recurrence  of  lileeiliug,  and  the  rate  of  respiration.  The 
initial  dose  should  vary  fioni  i  to  f  of  a  grain,  according  to  the  age 
and  the  exigency  of  the  condition,  but  in  extreme  cases  a  full  grain  or 
more  may  be  given  within  a  relatively  short  time.  Among  aged  people 
and  children,  it  should  be  given  with  greater  caution,  as  fatal  results 
may  follow  large  indiscriminate  doses  at  both  extremes  of  life.  The 
size  and  frequency  of  subsequent  doses  must  be  determined  exclusively 
by  the  effect,  thus  demanding  of  the  physician  the  exercise  both  of 
courage  and  of  conservatism.  Cough  must  be  controlled,  bleeding 
arrested,  I'estlessness  assuaged,  and  the  i-espirations  maintained  under 
twenty  to  the  minute,  until  alarming  symptoms  have  gradually  subsided. 
Nausea,  which  often  supervenes  in  the  event  of  small  haphazard  doses 
given  at  irregular  intervals,  completely  disappears  if  the  patient  is 
continuously  maintained  in  a  condition  of  moderate  narcosis.  Upon 
gradual  suspension  of  the  drug  no  nausea  is  likely  to  be  exhibited. 

Another  remedy  of  exceecUng  value  is  atropin,  which  is  particularly 
advantageous  in  the  more  urgent  cases.  In  the  event  of  very  profuse 
hemorrhage,  it  may  be  given  in  an  initial  dose  of  -,'„  grain,  to  be  repeated 
only  after  .several  hours.  A  suggesfiim  <>!'  ils  ^dnd  el'lect  i-  untod  in  the 
redness  of  the  skin  occasioned  bj-  peripheral  (lilatatidu  imideut  to  vaso- 
motor paresis,  with  consequent  reduction  of  pressure  in  the  pulmonary 
circulation.  It  is  unwise,  however,  to  combine  injudicious  atropin 
medication  with  correspondingly  large  doses  of  morphin.  Upon  the 
development  of  bronchopneumonia  from  the  inundation  of  the  bronchial 
tract  with  inspired  blood,  the  atropin  in  small  doses  is  of  some  value  as 
a  respiratory  stimulant. 

Upon  the  advent  of  bronchopneumonia.  \\\\\v\\  is  a  most  alarming 
sequel  of  pulmonary  hemorrhage,  the  moi)iliiii  -hould  be  immediately 
suspended.  At  such  a  time  the  drug  ])r(i(luies  harmful  results  by 
blunting  the  cough,  which  is  now  peculiarly  advantageous.  Inasmuch 
as  a  cessation  of  bleeding  always  takes  place  with  the  onset  of  this 
much-dreaded  complication,  the  necessity  for  its  administration  no 
longer  exists.  The  remedial  indications  consist  of  a  prompt  exhibition 
of  cardiac  stimulants,  occasional  inhalations  of  various  kinds,  a  possible 
vaccine  or  serum  therapy,  and  sometimes  venesection  and  salt  infusion. 

Among  the  heart  stimulants,  strychnin  and  alcohol  should  take 
foremost  rank  in  preference  to  digitalis,  spartein,  or  adrenalin.  Their 
certainty  of  action  as  general  or  cardiac  stimulants  is  more  pronounced, 
and  a  broader  margin  established  between  therapeutic  and  toxic  effects. 
Stimulating  inhalants  are,  as  a  rule,  of  very  doiditful  efficacy,  though 
apparently  beneficial  effects  sometimes  are  noted  from  the  inhalation 
of  turpentine,  benzoin,  balsam  of  Peru,  phenol,  etc.  During  the 
severe  dyspnea  incident  to  septic   bronchopneumonia,  inhalations  of 


720  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

oxygen  add  greatly  to  the  comfort  of  the  patient,  though  rarely  instru- 
mental in  the  saving  of  life.  Almost  insuperable  chfRculties  are  found 
in  the  way  of  rational  vaccine  therapy  on  account  of  the  frequent  impos- 
sibility of  securing  sputum  for  the  mailing  of  a  vaccine,  and  the  rapid 
approach  of  dissolution. 

Venesection  is  permissible  in  the  presence  of  a  laboring  or  dilated 
right  heart,  highly  elevated  blood-pressure,  pulmonary  edema,  cyanosis, 
and  coma.  Tlie  degree  of  temporary  improvement  is  often  astonishing 
and  quite  beyond  the  imagination  of  those  unfamiliar  with  the  effect 
of  this  procedure  in  such  desperate  conditions.  Unfortunately,  a  per- 
manent change  for  the  better  is  secured  in  but  very  few  instances.  Vene- 
section should  be  invariably  accompanied  by  the  subcutaneous  injection 
of  hot  salt  solution,  which  is  very  frequently  of  value  as  a  cardiac  stimu- 
lant during  the  course  of  the  pneumonia.  At  times  of  extreme  urgency 
the  salt  solution  may  be  given  intravenously  in  order  to  avoid  loss  of 
time,  but  for  no  other  reason,  this  method  being  eminently  irrational 
vmless  the  necessity  for  haste  is  paramount.  Upon  three  or  four  occa- 
sions I  have  witnessed  sudden  death  in  the  midst  of  this  final  effort 
to  save  life.  Upon  the  other  hand,  imminent  death  has  been  averted 
in  several  instances  by  prompt  recourise  to  salt  infusion,  particularly 
during  the  collapse  following  an  extraordinarily  profuse  hemorrhage.  I 
have  in  mind  an  experience  of  several  years  ago  with  a  patient  suffer- 
ing almost  complete  exsanguination  from  a  frightful  hemorrhage,  which 
took  place  shortly  after  arrival  in  Colorado.  In  the  absence  of  palpable 
pulse  and  during  complete  coma,  with  gasping  respiration,  the  salt  solu- 
tion was  administered  as  a  last  resort  by  my  assistant.  Dr.  E.  W.  Emery, 
and  repeated  at  very  frequent  intervals  with  cardiac  stimulation  and 
oxygen  inhalations  during  the  next  few  days.  Despite  active  and  exten- 
sive tuberculous  involvement  of  both  lungs,  great  emaciation,  and  long- 
continued  fever,  the  patient,  after  the  lapse  of  a  year  and  a  half,  was 
enabled  to  engage  in  an  active  occupation.  During  the  past  two  years 
cough,  expectoration,  and  physical  signs  have  entirely  disappeared. 

The  contention  has  been  made  by  some  that  salt  solution  is  con- 
traindicated  after  profuse  hemorrhage,  upon  the  ground  that  with 
renewed  volume  of  circulation  and  increased  pressure,  the  bleeding  is 
likely  to  recur.  A  cautiously  supervisetl  infusion  following  drenching 
exsanguination  has  never  been  followed,  in  my  experience,  by  recurring 
hemorrhage.  It  should  be  remembered  that  the  bleeding  often  ceases 
long  before  death  occurs,  dissolution  taking  place  from  collapse  and 
inability  of  the  heart  to  contract  upon  a  greatly  diminished  volume  of 
blood.  The  deficiency  may  be  supplied  by  a  supplementary  infusion  of 
salt  solution,  while  the  tendency  to  thrombus  formation,  already  insti- 
tuted by  the  reduction  of  volume,  is  in  no  wise  lessened,  provided  an 
undue  excess  of  salt  solution  be  not  administered. 


SPECIAL   METHODS 

In  addition  to  the  use  of  salt  injections,  the  special  measures  worthy 
of  trial  from  time  to  time,  are  the  application  of  cold,  the  employment 
of  traction  plasters  to  constrict  the  chest,  and  the  use  of  ligatures  upon  the 
extremities. 

Cold  may  be  conducted  to  the  chest  in  several  ways,  i.  e.,  by  fre- 
quent application  of  cloths  previously  placed   upon   blocks  of  ice,  or 


TREATMENT  OF  PULMONARY  HEMORRHAGE  721 

saturated  with  ice-water,  by  the  employment  of  a  lead  coil  through 
which  ice-water  slowly  flows,  and  by  the  use  of  the  ice-bag.  The  objec- 
tion to  the  first  method  consists  of  the  almost  incessant  changing  of  the 
cloths,  to  which  the  nurse  must  devote  practically  her  entire  time.  The 
chest  of  the  patient  is  constantly  exposed  throughout  the  period  during 
which  this  method  is  practised.  While  perhaps  of  some  value  at  the 
time  of  copious  hemorrhage,  its  practical  utility  i.s  open  to  serious  doubt 
at  a  later  period.  On  account  of  the  unceasing  active  attendance 
required,  and  the  incidental  manipulation  of  the  patient,  it  is  extremely 
unlikely  that  this  practice  possesses  any  decided  superiority  o\'er  the 
use  of  the  ice-bag. 

The  employment  of  the  lead  coil  is  also  attended  by  some  dis- 
advantages. Its  weight  is  sometimes  quite  objectionable,  as  is  also  the 
necessity  of  frequent  attention  to  the  flow  of  water.  Upon  the  whole, 
no  special  advantages  are  secured  to  compensate  for  the  added  incon- 
venience. On  the  contrary,  it  is  probable  that  for  the  average  case  the 
inferiority  of  this  method  is  beyond  dispute.  Its  efficiency  has  been 
markedly  less  in  my  own  experience,  than  has  been  reported  by  others. 
Considerable  difficulty  is  met  in  maintaining  a  close  apposition  of  the 
coil  to  the  chest  wall,  on  account  of  the  rigidity  of  the  leaden  tubes. 
Failure  to  secure  juxtaposition  of  coil  and  soft  parts  is  particularly  notice- 
able among  emaciated  individuals  with  shrunken  rib-spaces.  Under 
these  circumstances,  the  non-flexible  tubes  are  found  to  rest  here  and 
there  upon  elevated  ribs  without  sufficient  coaptation  to  the  skin  to 
secure  practical  efficiency.  Some  of  the  cUsadvantages  incident  to  the 
lead  coil  are  obviated  by  using  a  coil  of  rubber  tubing. 

All  these  objections  are  removed  by  the  intelligent  employment 
of  the  ice-bag.  It  is  not  unduly  heavy,  as  it  need  not  be  completely 
filled  with  ice.  Its  use  is  attended  by  comparatively  no  inconvenience, 
and  the  cold  is  applied  to  the  skin  without  the  need  of  unremitting 
attention,  the  patient  being  quite  undisturbed  by  the  ice-bag.  Necro- 
sis of  the  soft  parts  may  be  prevented  by  the  intervention  of  protect- 
ing gauze  between  the  bag  and  the  skin.  It  is,  of  course,  essential 
that  the  ice  be  replenished  at  not  infrequent  intervals,  as  the  presence 
of  a  rubber  bag  containing  water  is  not  conducive  to  the  best  results. 
Further,  the  position  of  the  ice-bag  upon  the  abdomen  where,  owing 
to  the  carelessness  of  the  nurse,  it  too  often  is  found,  is  not  in  accord 
with  the  principles  of  its  employment.  In  the  same  way  its  application 
over  the  lung,  from  which  bleeding  does  not  ensue,  is  unlikely  to  exert 
any  direct  influence  against  the  recurrence  of  hemorrhage.  Erro- 
neous conclusions  as  to  the  particular  lung  from  which  the  loss  of  blood 
takes  place  are  far  more  frequent  than  might  be  supposed.  In  case 
both  lungs  are  involved,  it  is  not  always  easy  to  differentiate  by  the 
physical  signs,  the  unilateral  origin  of  the  hemorrhage,  nor  is  it  wise 
in  general  to  examine  the  chest  at  this  time.  If  one  lung  is  but 
slightly  diseased  and  the  other  unaffected,  difficulty  in  determining 
the  precise  area  of  tuberculous  infection  is  sometimes  encountered  by 
inexperienced  examiners.  I  have  under  observation  a  patient  recently 
sent  to  Colorado  following  a  series  of  small  hemorrhages,  which  occurred 
during  a  period  of  two  weeks.  Throughout  this  entire  time  an  ice-bag 
was  kept  upon  the  anterior  chest  wall  of  the  sound  lung,  the  signs 
at  the  other  apex  having  been  sufficiently  obscure  to  escape  detec- 
tion.    The  application  of  the  ice-bag  over  the  heart  is  often  of  signal 


722  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

value,  particularly  in  case  of  marked  arterial  excitement.  In  some 
cases  greater  importance  may  be  attached  to  the  position  of  the  ice-bag 
over  the  cardiac  area,  than  over  the  supposed  site  of  pulmonary  hemor- 
rhage. 

Constriction  of  the  chest  by  means  of  tight  strapping  with  rubber 
adhesive  plaster  constitutes  a  not  uncommon  procedure.  As  usually 
employed,  overlapping  strips  are  drawn  tightly  from  sternum  to  spine 
over  the  side  corresponding  to  the  lung  from  which  the  hemorrhage 
is  supposed  to  take  place.  The  principle  invoked  is  the  restriction  of 
respiratory  movements  as  far  as  possible  upon  the  affected  side.  This 
curtailment  of  function  is  in  part  compensated  for  by  the  supplemental 
exaggerated  function  of  the  other  lung.  It  is  at  once  apparent  that, 
in  addition  to  the  impropriety  of  subjecting  the  patient  at  such  a  time 
to  a  physical  exploration  of  the  chest,  an  error  in  differentiating  the 
site  of  hemorrhage  must  be  singularly  unfortunate  in  that  the  sound 
lung  would  become  crippled  in  efficiency,  while  a  greater  burden  would 
be  imposed  upon  the  damaged  lung  of  the  unrestricted  side.  It  is  not 
entirely  clear  that  the  important  underlying  principle  should  be  an 
effort  to  minimize  the  use  of  the  aft'ei-tcil  hiuii,  but  rather  to  reduce 
the  depth  of  the  respiratory  excursion  iipnii  Imlli  sides.  Equally  good 
results  seem  to  be  obtained  through  the  const lictKin  of  the  entire  chest 
by  a  single  broad  strip  of  rubber  adhesive  plaster,  tightly  encircling  the 
ribs  below  the  nipple.  A  very  considerable  advantage  of  this  simple 
procedure  is  the  ease  with  which  the  constricting  band  is  applied  with- 
out appreciable  disturbance  of  the  patient.  In  sharp  contrast  is  the 
difficulty  experienced  in  applying  tightly  overlapping  unilateral  straps, 
as  in  this  event  the  patient  must  be  turned  upon  the  side  and  the  trac- 
tion distributed  to  less  advantage.  For  the  same  reason,  the  employ- 
ment of  ingeniously  devised  traction  plasters  designed  to  restrict  power- 
fully the  movements  of  one  side,  or  to  compress  pulmonary  cavities, 
are  not  always  of  practical  value  in  cases  of  pulmonary  hemorrhage, 
on  account  of  the  difficulties  of  their  intelligent  application  without 
undue  disturbance  of  the- invalid.  If  the  indications  are  sufficiently 
urgent  to  point  to  the  advisability  of  retarding  the  rpspiratory  move- 
ments at  all,  the  prime  desideratum  should  be  the  product  ion  of  restric- 
tion in  the  simplest  possible  manner.  This  is  secured  witli  i^erfect  ease 
by  the  use  of  a  broad  incircling  strap  of  rubljer  adhesive  plaster. 

Ligation  of  the  extremities  has  proved  exceedingly  effective  in  the 
control  of  alarming  pulmonary  hemorrhage.  While  some  clinicians 
have  been  led  to  doubt  its  utility,  my  own  experience  has  been  strongly 
confirmatory  of  the  claims  presented  by  its  early  advocates.  The 
method  is  not  to  be  recommended  save  in  the  presence  of  rather  copious 
hemorrhages,  with  tendency  to  frequent  recurrence.  The  ligature 
should  be  applied  around  the  limb  not  far  from  the  trunk,  and  should  be 
sufficiently  tight  to  compress  the  veins  but  not  the  arterial  vessels.  The 
principle  involved  is  the  reduction  of  blood  volume  in  the  lung,  as  a 
result  of  preventing  the  return  of  the  venous  circulation  in  the  extremi- 
ties. Coldness  or  cyanosis  of  the  hands  or  feet  must,  of  course,  be 
avoided.  In  desperate  cases  it  has  been  my  custom  to  keep  the  liga- 
ture closely  applied  for  much  longer  periods  than  usually  advised — 
in  some  instances  for  an  entire  day — without  disagreeable  result.  It 
is  very  important  that  the  bandages  be  removed  with  the  utmost 
caution,  it  being  urged  that  they  be  gently  loosened  one  at  a  time, 


GENERAL  DRUG  THERAPY  723 

with  intervening  periods  of  not  less  than  one-half  hour.  I  recall 
an  illustrative  incident,  occurring  many  years  ago,  when  in  attend- 
ance, throughout  an  entire  night,  upon  a  patient  suffering  from 
repeated  terrifying  hemorrhages  during  the  temporary  absence  of 
the  attending  physician.  Ligatures  were  placed  upon  all  four  e.xtremi- 
ties  close  to  the  body  and  the  loss  of  blood  eventually  controlled  through 
their  influence.  The  following  morning,  upon  the  arrival  of  the  physician 
in  charge,  all  the  ligatures  were  quickly  removed,  with  an  immediate 
resulting  deluge  of  blood  from  the  mouth  of  the  patient,  and  instan- 
taneous death. 


CHAPTER  XCVIII 
GENERAL  DRUG  THERAPY 

The  routine  administration  of  drugs  to  pulmonary  invalids,  which 
has  been  so  largely  in  vogue  for  many  years,  has  been  the  immediate 
cause  of  an  untold  amount  of  harm.  The  adoption  of  this  pernicious 
practice  in  the  treatment  of  all  clas.ses,  regardless  of  the  character  of 
the  remedy  or  existence  of  special  indications,  has  been  responsible  for 
two  conspicuous  evils — the  directly  injurious  effect  upon  the  disiostive 
functions,  and  the  enormous  loss  of  time  and  (ipjiorhiiiilii  sulTcicd  by 
consumptives  in  seeking  hygienic,  dietetic,  antl  cliiuuiii'  :k1\  jiitaiics. 
No  words  of  condemnation  concerning  the  indiscrimiuute  and  i,i;ii()- 
rant  employment  of  drugs  can  too  strongly  stamp  the  disapproval  of 
the  profession.  There  can  be  no  dissenting  opinion  that  the  ,i;en(!ral 
practitioner  should  be  encouraged  to  utilize  to  a  far  greater  cxtont  tlie 
facilities  for  recovery  offered  by  superalimentation,  rest,  oiihlnin'  li\  iiig, 
and  climate.  Furthermore,  he  should  be  urged  to  discard  the  comcn- 
tional  exhibition  of  cough  syrups,  tonics,  hypophosphites,  mult  jtrepara- 
tions,  and  emulsions  with  which  the  market  is  surfeited.  Upon  the 
other  hand,  there  should  be  condemned  with  equal  emphasis  the  pre- 
vailing tendency  to  decry  the  administration  of  any  drug  whatever, 
irrespective  of  its  nature  and  the  exigency  of  the  demand.  Some 
specialists  in  tuberculosis  have  denied  in  toto  the  value  of  medication 
for  almost  any  aspect  of  the  disease.  The  former  tendency  toward 
the  administration  of  drugs  to  the  exclusion  of  rational  measures  has 
given  way  to  such  a  reversal  of  sentiment  that  the  use  of  important 
remedies  to  meet  urgent  symptomatic  indications  is  often  met  with 
strenuous  objections.  To  such  an  extent  have  the  susceptibilities  of 
general  practitioners  and  patients  been  played  upon  regarding  the 
supposed  disadvantages  of  all  mecUcine  for  the  consumptive,  that  an 
unreasoning  prejudice  against  its  employment  has  become  a  popular 
fad.  Thus,  unnecessary  embarrassment  is  occasioned  to  the  resource- 
ful physician,  who  seeks  to  utilize  the  beneficial  effects  of  judicious 
medication,  in  order  to  control  untoward  symptoms. 

Without  desire  to  condone  the  ignorance  responsible  for  indis- 
criminate dosage,  the  conviction  is  sustained  by  practical  experience, 
that  an  intelligent  exhibition  of  a  few  remedies  to  meet  the  varying 
needs  and  requirements  of  tuberculous  invalids  is  eminently  proper, 


724  PROPHYLAXIS,    GEiNEllAL    AND    SPECIFIC    TREATMENT 

and  constitutes  a  valuable  adjuvant  to  more  important  measures.  It 
would  seem  that  quite  as  much  evil  may  be  expected  from  allegiance 
to  the  principles  of  medicinal  nihilism,  as  from  persistent  adherence 
to  the  old-fashioned  doctrine  of  overmedication.  Protest,  therefore,  is 
offered  against  the  inculcation,  in  the  popular  mind,  of  delusions  con- 
cerning the  non-utUity  of  all  drugs  for  the  pulmonary  invalid.  To  deny 
their  occasional  favorable  influence  in  the  practice  of  discerning,  dis- 
criminating, and  resourceful  clinicians  is  as  idle  as  to  repudiate  the 
known  advantages  of  hygienic  measures  and  climate. 

In  the  management  of  special  symptoms,  it  has  been  insisted  that 
the  treatment  should  be  conducted  along  the  lines  of  hygienic  methods, 
but  that  due  recognition  should  be  accorded  to  the  intrinsic  merit  of 
judicious  drug  therapy.  The  suppression  of  hemorrhage,  the  restora- 
tion of  disordered  digestion,  and  the  alleviation  of  various  disturbed 
functions  are  often  wondrously  facilitated  by  the  employment  of  appro- 
priate medication.  It  cannot  be  asserted  that  equally  beneficial  results 
are  obtained  by  the  employment  of  drugs  for  their  general  effect.  In 
fact,  the  indications  for  general  drug  therapy  are  exceedingly  few  and 
relatively  unimportant.  In  selected  cases,  however,  some  value  may 
be  attached  to  the  administration  of  strychnin,  arsenic,  creasote,  and 
preparations  of  emulsified  fats. 

Strychnin  is  often  of  advantage  through  its  influence  as  a  general 
stimulant.  In  physiologic  doses  it  is  supposed  to  exert  an  effect  upon 
all  body  functions.  By  virtue  of  its  stimulation  of  the  nervous  system 
the  activity  of  the  vital  processes  of  cell  nutrition  are  correspondingly 
promoted.  It  is  thought,  with  increased  functional  activity,  added 
defense  is  acquired  against  the  tuberculous  infection.  It  has  been 
claimed  by  some  that  the  maximum  benefit  from  the  exhibition  of  this 
drug,  may  occur  only  when  the  do.se  is  progressively  increased  to  the 
limit  of  physiologic  toleration.  The  amounts  reported  to  have  been 
administered  without  toxic  effect  by  enthusiastic  advocates  of  strychnin 
therapy  for  consumptives,  almost  surpass  understanding,  in"  some 
instances  a  grain  of  the  drug  having  been  given  daily  for  prolonged 
periods  without  unpleasant  effects.  While  it  may  be  accepted  as  capa- 
ble of  clinical  demonstration,  that  the  best  effects  follow  its  employ- 
ment in  considerably  larger  doses  than  have  formerly  been  given,  its 
routine  administration  in  increasing  doses  should  not  be  encouraged. 
It  is  po.ssible  that  unusual  conditions  may  exist  suggesting  the  expe- 
diency of  the  maximum  physiologic  dosage,  but  the  employment  of  the 
drug  at  other  times,  save  to  a  judicious  extent,  should  be  deprecated. 
Generally  speaking,  in  the  absence  of  special  contraindications,  good 
results  may  be  expected  among  pulmonarj'  invalids  by  the  adminis- 
tration of  ^V  grain  three  or  four  times  daily.  Under  its  influence 
the  appetite  and  general  functional  activities  are  often  advantageously 
stimulated. 

It  has  been  my  custom  for  many  years  to  combine  the  administration 
of  arsenic  with  that  of  strychnin,  although  never  as  a  routine  procedure. 
Through  the  employment  of  Fowler's  solution,  which  is  perhaps  the 
best  form  for  administration,  the  promotion  of  appetite  is  sometimes 
pronounced.  On  account  of  the  narrow  margin  between  the  therapeutic 
and  toxic  doses  it  is  es.sential  that  extreme  care  be  exercised  in  its  employ- 
ment. It  should  be  given  in  beginning  doses  of  one  minim  three  times 
a  day,  which  may  be  cautiously  increased  to  five  minims.     The  remedy 


GENERAL  DRUG  THERAPY  725 

should  not  be  taken  in  less  than  one-half  glass  of  water  after  each 
meal,  and  should  be  promptly  suspended  upon  the  appearance  of 
nausea  or  other  disagreeable  symptoms.  As  a  rule,  it  is  unwise  to  persist 
continuously  in  the  use  of  this  preparation  for  a  longer  period  than  two 
months,  when  there  maj'  be  substituted  to  advantage  agreeable  prepara- 
tions of  iron.  In  the  event  of  dry,  spasmodic  cough  the  syrup  of  hydri- 
odic  acid  may  often  be  administered  with  gratifying  results. 

Unfortunately,  creosote  has  been  regarded  for  many  years  as  of 
essential  value  by  numerous  practitioners.  For  three-quarters  of  a 
century,  with  varying  degrees  of  enthusiasm,  the  supposed  specific 
action  of  this  drug  has  been  highly  vaunted.  Its  value  at  first  was 
thought  to  consist  of  a  certain  inhibiting  influence  upon  the  growth 
of  tubercle  bacilli,  and  its  greatest  efficacy  was  thought  to  follow  its 
maximum  administration  by  way  of  the  digestive  tract.  In  the  majority 
of  cases  it  was  found  that  in  large  doses,  the  entrance  of  this  drug  into 
the  stomach  was  followed  by  indigestion,  disagreeable  eructations, 
repugnance  for  food,  vomiting  and  diarrhea,  with  occasional  nephritic 
disturbance.  Routine  persistence  in  its  employment  despite  the 
manifestations  of  gastric  rebellion,  has  often  resulted  in  incalcul- 
able damage,  the  initial  loss  of  appetite  and  digestive  derangement 
apparently  becoming  confirmed.  It  must  be  admitted,  however,  that 
in  exceptional  instances,  very  material  benefit  has  followed  its  use, 
notably  an  improvement  of  appetite  and  digestion  and  disinfection  of 
the  intestinal  canal,  in  cases  of  flatulence  and  fermentative  diarrhea. 
Other  effects  have  occasionally  been  noted  among  patients  with  exces- 
sive, purulent,  and  heavy  expectoration.  It  is  apparent  that  in  the 
overwhelming  majority  of  cases,  creasote  must  be  regarded  as  an  agent 
capable  of  producing  a  definite  amount  of  harm,  but  among  a  com- 
paratively few  presenting  possibilities  of  some  benefit  if  intelligently 
and  cautiously  administered.  For  general  ii,se  it  cannot  be  condemned 
too  emphatically,  for  the  unfortunate  results  far  overshadow  the  isolated 
instances  of  improvement.  The  most  that  can  be  said  in  its  behalf  is 
that  it  has  a  valid  claim  for  tentative  employment  among  a  compara- 
tively few  ca.ses.  It  should  be  administered,  if  at  all,  in  small  initial 
doses  of  not  over  one  or  two  minims,  preferably  in  capsules,  and  increased 
but  moderately.  Its  use  should  be  restricted  to  intractable  cases  of 
gastric  and  intestinal  fermentation,  with  impaired  appetite,  chronic 
bronchitis,  or  bronchiectasis  complicating  tuberculosis,  and  pulmonary 
excavation  attended  by  profuse  purulent  expectoration.  Furthermore, 
it  should  be  promptly  discontinued  as  soon  as  it  becomes  apparent 
that  the  appetite  and  digestion  are  impaired  by  the  drug.  But  little 
confidence  may  be  reposed  in  its  practical  utility  for  the  purposes  of 
inhalation.  The  many  derivatives  of  creasote  have  been  found  less 
advantageous  than  the  crude  article. 

Several  preparations  of  cod-liver  oil  and  easily  digested  fats  must 
be  accepted  as  possessing  certain  advantages  for  a  class  of  pulmonary 
invalids.  The  only  benefit  represented  by  the  administration  of  such 
agents,  is  reflected  in  the  ingestion  of  a  generous  amount  of  easily  digested 
fat.  Much  discrimination  should  be  exercised  in  the  employment  of 
these  preparations  on  account  of  their  frequent  effect  in  retarding  diges- 
tion. Obviously,  they  should  not  be  given  to  patients  with  fever  and 
pronounced  gastric  derangement.  In  general,  they  are  borne  much 
better  in  the  winter  than  during  the  hot  summer  months.     Their  special 


726  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

utility  is  found  in  the  treatment  of  individuals  who,  on  account  of 
straightened  financial  circumstances,  are  not  favored  by  an  overabun- 
dance of  good  nutritious  food.  Thus  these  preparations  have  been  of 
considerable  service,  chiefly  among  dispensary  patients,  and  other  con- 
sumptives, but  sparingly  endowed  with  this  world's  goods.  The  neces- 
sity for  their  employment  is  much  less  when  the  patient  is  supplied  with 
large  quantities  of  cream,  butter,  and  eggs. 


SECTION    III 
Specific  Treatment 


CHAPTER  xrix 
THEORIES  OF  IMMUNITY 

The  underlying  principle,  upon  which  have  been  based  all  efforts 
in  the  way  of  biologic  therapy  in  tuberculosis,  is  the  production  of  arti- 
ficial immunity  by  the  introduction,  into  the  body,  of  some  bacterial 
agent  stimulating  resistance  to  infection.  It  is  becoming  established 
that  effective  means  are  available  for  the  reinforcement  of  the  natural 
but  complex  processes  of  immunity.  The  present  recognition  of  the 
possible  stimidation  of  the  defensive  resources  of  the  organism  by  arti- 
ficial means,  has  been  of  slow  development,  but  the  overwhelming  logic 
of  experimental  research  and  of  clinical  experience  appears  to  be  well- 
nigh  irresistible.  It  can  no  longer  be  disputed  that  in  many  instances, 
through  the  employment  of  immunizing  substances,  results  of  consider- 
able value  may  be  achieved.  In  conceding  the  clinical  efficiency  of 
specific  medication  as  at  present  employed,  a  tribute  of  the  highest 
honor  should  be  paid  to  the  numerous  workers  through  whose  inde- 
fatigable labors  in  the  midst  of  almost  insurmountable  obstacles,  the 
evolution  of  our  present  knowledge  has  been  made  possible.  Before 
proceeding  to  the  clinical  application  of  the  principles  upon  which 
depend  the  production  of  an  artificial  resistance  to  tuberculous  infec- 
tion, it  is  well  to  present  a  brief  historic  sketch  of  the  various  experi- 
mental contributions  bearing  upon  the  relation  of  culture  products  to 
immunity. 

The  first  endeavor  to  produce  an  artificial  immunity  to  tuberculosis 
originated  with  Koch,  who  observed  essential  differences  following  the 
inoculation  of  pure  cultures  of  tubercle  bacilli  in  healthy  and  in  tubercu- 
lous guinea-pigs.  In  the  former  the  sequence  of  local  changes  consisted  of 
apparent  healing,  the  formation  of  a  hard  nodule  in  ten  to  fourteen  days, 
and  a  subsequent  persistent  ulcer  until  the  death  of  the  animal.  In 
pigs  already  tuberculous,  there  was  an  initial  attempt  at  healing,  followed 
shorth'  by  necrosis  of  skin  and  superficial  ulceration,  which  soon  healed 
permanently.  Dead  bacilli  were  found  to  produce  no  general  effect 
when  injected  into  healthy  animals,  but  prolonged  the  life  of  those 


THEORIES    OF    IMMUNITY  727 

already  infected.  As  a  result  of  these  experiments,  tuberculous  animals 
were  assumed  to  acquire  immunity  against  reinfection,  but  there  was  no 
evidence  pointing  to  a  successful  resistance  of  the  previous  infection. 
It  was  apparent,  however,  that  some  specific  influence  was  exerted  by 
the  products  of  the  dead  tubercle  bacilli. 

Tuberculin,  which  was  reported  to  the  profession  by  Koch  in  1890, 
■was  at  once  hailed  as  a  specific,  and  widely  administered.  It  was  made 
by  evaporating  glycerin  bouillon  cultures  of  the  tubercle  bacillus  in  a 
water-bath  to  one-tenth  of  its  volume.  The  dead  bacilli  were  filtered, 
the  tuberculin  in  the  filtrate  containing  40  to  50  per  cent,  of  glycerin. 
When  dilutions  are  made  of  this  product,  phenol  is  added  for  the  pur- 
pose of  preservation. 

A  brief  resume  of  the  more  prominent  effects  of  this  agent  is  of  some 
interest,  though  familiar  to  all  students  of  immunity.  Curiou.sly,  it 
was  found  in  small  doses  to  exert  but  little  influence  in  well  people,  but 
to  produce  striking  phenomena  in  the  tuberculous.  The  innocuousness 
of  its  administration  to  healthy  individuals  has  been  ascribed,  according 
to  Flexner  and  others,  to  a  combination  of  the  active  principles,  from 
which  the  toxic  substance  is  incapable  of  separation,  save  in  the  tuber- 
culous foci  of  infected  individuals.  Ingenious  as  is  this  explanation, 
it  is  difficult  of  reconciliation  with  the  known  fact  of  its  profoundly 
poisonous  influence  in  the  non-tubcicnlous,  if  given  in  doses  somewhat 
larger  than  employed  for  those  aliciuly  inlccicd.  It  was  found  to  pro- 
duce, after  a  few  hours,  severe  coiislitutidiial  .'^lymptoms,  consisting  of 
chill,  headache,  vomiting,  high  fever,  rapid  pul.se,  prostration,  and  sweat- 
ing. The  convalescence,  as  a  rule,  was  prompt.  Among  patients  with 
even  slight  tuberculous  involvement  similar  effects,  known  as  the  gen- 
eral reaction,  followed  much  smaller  do.ses.  In  circumscribed  or  external 
tuberculous  processes  a  more  or  less  defined  local  reaction  was  observed, 
consisting  of  pain,  swelling,  tenderness,  and  visual  engorgement.  In 
some  cases  of  pulmonary  phthisis,  cough  was  temporarily  aggravated, 
and  complaint  made  of  soreness  or  tightness  of  the  chest,  with  shortness 
of  breath.  Hemorrhage  sometimes  ensued  a  few  hours  after  the  injec- 
tion, but  this  was  not  usiuilly  attended  by  serial  recurrences.  Areas 
of  increa.sed  dulness  were  (Hcusionally  recognized,  together  with  added 
moisture  in  the  finer  lironc  IikiIi's.  The  violence  of  the  general  reaction 
was  often  greatly  disprop(ii-ti(in;iir  to  the  local  cvidcures.  but  the  latter 
sometimes  resulted  without  -yniptdin-  of  coiistitutional  disturbance. 
Marked  differences  existed  hi  the  .■.us(ci)tiliility  of  individuals  and  of 
the  same  person  at  various  times.  Repeated  inoculations  appeared  to 
confer  a  striking  indifference  on  the  part  of  the  organism  to  subsequent 
injections,  but  increased  susceptibility  to  reaction  returned  after  dis- 
continuance of  the  injections. 

Incalculable  damage  was  inflicted  by  its  reckless  employment  by 
inexperienced  clinicians,  and  in  some  instances  from  its  administration 
even  by  well-trained  observers.  Failure  to  demonstrate  its  practical 
value,  together  with  the  popular  recognition  of  its  disadvantages, 
speedily  resulted  in  an  era  of  violent  condemnation.  During  a  period 
of  fifteen  years,  from  1890  to  1905,  the  wave  of  repudiation  increased 
in  volume  and  power  until  its  effect  appeared  almost  overwhelming. 

In  the  mean  time,  through  an  appreciation  of  its  complex  but  subtle 
influence  upon  tuberculous  processes,  many  students  were  inspired  to 
continue  investigations  in  the  hope  of  discovering  a  modified  tuberculin 


728  PROPHYLAXIS,    GENERAL    AXD    SPECIFIC    TREATMENT 

that  would  j-ield  satisfactory  results.  Numerous  preparations  were 
used  in  an  effort  to  produce  among  animals  artificial  immunity  to  a 
subsequent  tuberculous  infection.  These  were  also  employed  to  a 
wide  extent  as  therapeutic  agents.  Koch,  in  an  endeavor  to  make  a 
preparation  containing  the  toxins  of  the  bacillus  suitable  for  therapeutic 
employment,  presented  the  tuberculin  TR.  Virulent  cultures  of  tubercle 
bacilli,  after  being  dried  in  vacuum,  were  thoroughly  pulverized.  Upon 
the  addition  of  distilled  water,  centrifuging  was  employed  for  three- 
quarters  of  an  hour  at  the  rate  of  4000  revolutions  to  the  minute.  The 
white,  opalescent  fluid  in  the  upper  portion  was  designated  TO,  and  the 
slimy  residuum.'TR.  The  supernatant  fluid  was  aspirated,  the  residuum 
mixed  with  more  distilled  water,  and  the  centrifuging  process  repeated. 
The  tuberculin  TO  represented  the  soluble  components  in  glycerin  and 
was  similar  in  its  effect  to  the  old  tuberculin.  The  TR  contained  the 
insoluble  parts  in  a  fine  emulsion,  representing  all  the  immunizing  sub- 
stances, and  was  capable  of  absorption.  To  this  20  per  cent,  glycerin 
was  added.  His  more  recent  preparation  is  the  l)acilli  emulsion,  which 
is  a  suspension  of  pulverized  bacilli  in  water  with  an  equal  amount  of 
glycerin.  This  was  presented  to  the  profession  in  1901.  A  variety  of 
agents,  all  of  which  comprise  some  modification  of  the  original  tubercu- 
lin, were  advanced  l^y  Klebs,  Maragliano,  Hirschfelder,  Hahn,  Land- 
mann,  von  Ruck,  and  Behring.  It  was  found  that  the  injection  of  pul- 
verized living  or  dead  bacilli  produced  for  a  time  an  increased  resistance 
to  tuberculous  infection,  but  not  sufficiently  to  withstand  completely  a 
previous  bacillary  invasion.  In  other  words,  the  relative  immunity 
produced  was  not  permanent  nor  especially  pronounced. 

It  became  quite  definitely  established  that  immunity  could  be  con- 
ferred upon  some  animals  by  inoculation  with  living  attenuated  tubercle 
bacilli.  Dixon,  in  1889,  in  experiments  upon  guinea-pigs  and  rabbits, 
found  that,  after  inoculation  with  cultures  of  slight  virulence,  an 
apparent  immunity  from  subsequent  infection  was  secured.  In  1890 
and  1891  experiments  of  this  nature  were  performed  by  Martin, 
Grancher,  Ledoux-Lebard,  Courmont,  Dor,  Htricourt,  and  Richet,  in 
some  instances  use  being  made  of  attenuated  human  bacilli,  and  in 
others,  of  the  avian  variety. 

The  experiments  of  Trudeau  in  1892  and  189.3  are  of  great  interest 
and  have  often  been  quoted.  Rabbits  were  inoculated  twice  with  avian 
bacilli,  three  weeks  intervening  between  the  protective  treatments. 
Some  months  later  the  anterior  chamber  of  the  eye  was  inoculated  with 
virulent  mammalian  bacilli,  it  being  uncertain  whether  the  cultures 
were  of  human  or  bovine  type.  In  the  control  animals  a  slowly  pro- 
gressive degenerative  change  took  place  in  the  eye.  resulting  in  its  ulti- 
mate destruction.  Among  those  previously-  treated  with  a\'ian  inocu- 
lations, the  inflammatory  changes  were  manifested  much  more  rapidly, 
but  were  correspondingly  quick  to  subside,  disappearing  altogether 
after  a  few  weeks. 

DeSchweinitz,  in  1894,  inoculated  guinea-pigs  with  an  attenuated 
culture  of  human  tubercle  bacilli  cultivated  for  twenty  generations. 
This  was  not  found  virulently  infective  to  these  animals,  but  afforded 
an  undoubted  protection  against  further  inoculation,  as  was  shown 
when  they  were  later  subjected  to  the  injection  of  virulent  bovine  bacilli. 
These  remained  unaffected  while  the  control  animals  survived  but  six 
or  seven  weeks. 


THEORIES    OF    IMMUNITY  729 

In  1903  Ti-udeau  continued  his  investigations  upon  guinea-pigs,  in 
an  effort  to  determine  whether  his  previous  satisfying  attempts  toward 
the  production  of  artificial  immunity,  were  referable  solely  to  the  injec- 
tions of  the  living  bacillus.  He,  therefore,  in  his  later  experiments, 
made  use  both  of  living  attenuated  human  cultures,  and  of  dead  bacilli 
previously  subjected  to  steam  sterilization  for  fifteen  minutes.  A  second 
inoculation  was  performed  one  month  later.  At  this  time  a  slight 
enlargement  of  the  inguinal  glands  was  noted  in  those  receiving  attenu- 
ated living  bacilli,  while  the  animals  inoculated  with  dead  bacilli 
were  apparently  unaffected.  In  another  month  all  were  subjected  to 
inoculation  with  virulent  human  bacilli,  together  with  an  equal  number 
of  controls.  All  the  latter  were  dead  in  ninety  days,  exhibiting  upon 
examination  extensive  general  infection  of  organs.  A  considerable 
number  of  the  animals  inoculated  with  dead  bacilli  had  also  succumbed, 
but  this  was  not  true  of  a  single  pig  injected  with  attenuated  living 
cultures.  The  pathologic  changes  in  the  control  animals  were  very 
similar  to  those  in  the  pigs  inoculated  with  dead  bacilli.  On  the  other 
hand,  the  pathologic  lesions  in  those  injected  wuth  living  bacilli  were 
comparatively  insignificant,  there  being  no  evidence  of  caseation. 

Great  interest  attaches  to  experiments  performed  upon  cattle  in  an 
effort  to  produce  artificial  immunity.  Much  work  has  been  done  and 
results  reported  liy  llacFadyean,  Behring,  Pearson,  Gilliland,  and  others. 

MacFadyean,  early  in  1901,  after  intravenous  inoculation  of  several 
cattle,  two  of  which  were  tuberculous,  with  living  cultures  of  tubercle 
bacilli,  found  that  their  resistance  to  infection  was  remarkably  increased. 
Later  in  the  same  year  Behring  began  experimental  work  upon  a  large 
scale,  with  a  view  to  produce  artificial  immunization  of  cattle.  After 
having  secured  rather  indifferent,  if  not  entirely  unsuccessful,  results 
from  the  use  of  tuberculin  and  its  modifications,  he  succeeded  in  immun- 
izing these  animals  with  attenuated  cultures  of  living  tubercle  bacilli 
of  bovine  origin.  A  culture  of  human  bacilli  of  low  virulence  was  given 
to  many  cattle,  and  followed  by  another  of  increased  activity  after  a  few 
months.  It  was  found  that  an  enormous  tolerance  to  virulent  tuber- 
culous infection  from  the  bovine  bacillus  was  established.  Inoculations 
with  such  infective  material  were  usually  attended  by  no  appreciable 
results,  while  control  animals  unprotected  by  previous  inoculation 
succumbed  in  a  few  weeks.  The  duration  of  the  period  of  immunization 
has  not  been  definitely  determined.  Pearson  has  shown  conclusively, 
from  references  contained  in  an  exhaustive  and  valuable  article  recently 
published,  that  Behring' s  belief  concerning  the  prolonged  duration  of 
the  immunity  has  not  been  supported  by  subsequent  facts  in  many 
instances. 

Recently  experiments  have  been  made  at  Melun,  in  the  Department 
of  Seine  et  Marne,  by  Valle.  In  February,  1905,  Dutch  cows,  Limousin 
bulls,  and  Normandy  cattle,  all  young  and  healthy,  were  treated  by 
injections  of  a  vaccine  prepared  by  Valle  in  accordance  with  Behring's 
method.  In  the  following  June  all  were  subjected  to  inoculation  with 
virulent  bovine  cultures.  Seven  of  the  same  age  and  race  were  inoculated 
subcutaneously,  as  were  an  equal  number  of  controls.  In  one  month  all 
the  control  animals  exhibited  extensive  tuberculous  change,  while  only 
one  or  two  of  those  vaccinated,  exhibited  even  the  slightest  trace  of 
infection.  Six  others  were  inoculated  intravenou.sly.  The  vaccinated 
animals  remained  apparently  unaffected,  while  the  controls  became 


730  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

seriously  ill,  three  dying  within  two  weeks.  Another  set  of  animals 
were  placed  side  by  side  with  tuberculous  cows  in  the  same  shed  and 
inclosure.  Resistance  to  infection  was  found  in  those  protected  by 
previous  inoculations,  while  advanced  tuberculous  change  was  recog- 
nized at  autopsy  among  the  controls.  It  is  of  further  interest  to  note 
that  immunization  of  cattle  through  the  digestive  tract  has  been 
reported.  Roux  and  Valle  have  very  recently  recorded  experiments  of 
this  nature.  Cultures  of  living  tubercle  bacilli  were  fed  sparingly  to 
young  calves,  and  the  reported  resulting  immunity  was  shown  by  the 
tuberculin  test.  Calmette  and  Guerin  have  reached  the  same  con- 
clusion as  to  the  production  of  immunity  through  the  alimentary  tract. 

The  experimental  investigations  thus  far  reported  have  been  suf- 
ficient to  demonstrate  beyond  question  the  active  protective  influence 
resulting  from  inoculations  of  living  attenuated  cultures  of  tubercle 
bacilli.  It  has  also  been  shown  that  injections  of  dead  bacilli  in  animals 
do  not  exert  more  than  a  fleeting  or  partial  immunity. 

The  early  researches  of  Koch  in  connection  with  tuberculin,  and  of 
other  workers  upon  its  various  modifications,  prepared  the  way  for  a 
recognition  of  the  increasing  tolerance  established  for  bacterial  toxins. 
There  was  suggested  the  possibility  of  securing  an  antituberculin  or 
antitoxin  capable  of  neutralizing  the  tuberculosis  toxins.  It  was  not 
altogether  appreciated  that  the  bacterial  toxins  of  tuberculosis  were 
but  partially  soluble  in  the  blood,  and  that  they  remained  more  or  less 
inwrapped  within  the  solid  substance  of  the  parasite.  It  was  assumed 
that  cliffusion  of  the  bacterial  poison  in  the  fluids  of  the  liody  took  place 
in  tuberculosis  as  in  diphtheria  and  tetanus.  Numerous  methods  were 
employed,  and  various  animals  utilized,  in  an  endeavor  to  secure  a 
supposed  immunizing  influence  from  the  blood  or  the  blood-serum. 

Maragliano  found  that  the  tuberculin  reaction  could  be  considerably^ 
diminished,  if  not  prevented  altogether,  by  the  simultaneous  adminis- 
tration of  the  serum  of  animals  to  whom  the  agent  had  previously  been 
given.  This  and  similar  experiences  by  others  with  the  serum  from 
\-arious  inoculated  animals,  were  attributed  to  the  presence  of  an  anti- 
tuberculin.  The  so-called  antitoxins  were  prepared  in  various  waj's, 
but  the  claims  made  concerning  their  merits  by  their  several  advocates, 
have  been  unsustained  by  animal  experimentation  or  clinical  observa- 
tion. 

In  the  meantime  Arloing  and  Courmont  called  attention  to  a  peculiar 
effect  produced  upon  tubercle  bacilli  contained  in  bacilli  emulsion,  by 
the  serum  of  tuberculous  individuals.  A  clumping  of  Iwcilli  was  recog- 
nized under  these  conditions,  and  the  reaction  was  termed  the  agglutina- 
tion test.  The  clumping  of  bacilli  is  more  "properly  a  sedimentation  or 
precipitation,  as  the  bacterial  emulsion  undoubtedly  holds  some  of  the 
toxins  in  solution,  and  tuberculin  injections  are  known  to  increase  the 
precipitating  power  of  serum.  Baldwin  has  shown  that  the  injection 
of  tuberculin  into  rabbits  is  followed  by  a  high  degree  of  precipitating 
power  of  the  l)lood-serum  for  the  tuberculin,  and  by  an  increased 
agglutination  capacity  for  bacilli  emulsion. 

For  many  years  Jlaragliano  has  devoted  much  patient  study  to  the 
subject  of  serum-therapy  for  pulmonary  tuberculosis.  He  has  made 
use  of  the  .serum  of  animals  previously  injected  with  toxins  and  the 
bodies  of  dead  bacilli.  He  has  contended,  since  1895,  that  a  serum 
could   be   produced   "rich   both   in   antibodies  and  antitoxins."     The 


THEORIES    OF    IMMUNITY  731 

proportion  of  these  substances  is  subject  to  much  variation  in  different 
sera,  and  depends  upon  the  manner  of  inoculating  the  producing 
animal.  The  amount  of  antitoxin  is  increased  if  the  animal  is  treated 
with  toxins,  and  the  number  of  antibodies,  if  treated  by  the  watery 
extract  from  the  bacilli  themselves.  His  doctrine  of  defense  consists  of 
the  formation  of  antibodies  and  the  consequent  power  of  agglutination. 
He  regards  the  agglutinating  power  as  a  measure  of  the  antibodies. 
This  reaction,  which  is  regarded  by  Koch  as  the  earliest  indication  of 
approaching  immunization,  is  believed  by  Maragliano  to  corre.spond  to 
the  development  of  bactericidal  properties  of  blood-serum.  The  latter  is 
subject  to  precise  determination  by  his  method  of  showing  an  attained 
immunization.  The  animal  is  subject  to  repeated  immunizing  injections 
until  the  serum  (which  is  subsequently  standardized)  is  found  to  exhibit 
a  sufficiently  high  power  of  agglutination.  He  asserts  that  new  anti- 
toxins and  new  antibodies  are  produced  by  the  introduction  of  the  serum 
into  the  human  organism,  and  that  they  supplement  the  natural  resisting 
processes.  He  concedes  that  the  general  oiganism  of  itself  is  responsible 
in  large  measure  for  the  increase  of  the  defensive  process  in  the  blood, 
and  hence  that  best  results  can  take  place  only  when  the  disease  is  not 
far  advanced,  general  nutrition  not  greatly  impaired,  and  mixed  infec- 
tion not  pronounced. 

Prior  to  the  discovery  of  the  tubercle  bacillus,  there  existed  widely 
prevalent  ideas  as  to  the  production  in  man  of  varying  degrees  of  immun- 
ity to  tuberculosis  from  the  preexistence  and  coexistence  of  certain 
other  diseases,  notably,  scrofula,  asthma,  chronic  bronchitis,  and  forms 
of  heart  disease  associated  with  venous  congestion  of  the  lungs.  The 
resistance  of  the  body  to  tuberculous  infection  in  the  midst  of  these 
conditions,  was  not  wholly  ascribed  to  the  influence  of  local  processes 
rendering  the  soil  unreceptive  to  a  deposit  of  tubercle,  but  rather  was 
attributed  to  a  certain  antagonism  between  the  diseases  in  question. 
Even  in  scrofula,  which  was  recognized  to  possess  some  relation  to  pul- 
monary phthisis,  there  w'as  exhibited  a  certain  stubbornness  to  general 
tuberculous  involvement,  suggesting  a  form  of  systemic  resistance. 

Later  statistical  observations  tended  to  confirm  the  early  supposition 
that  a  natural  immunity  was  conferred  upon  a  number  of  people  by  the 
very  pressence  of  a  tuberculous  affection.  This  was  illustrated  in  the  low 
mortality-rate  of  tuberculosis  in  comparison  with  its  high  morbidity. 
The  fact  that  from  85  per  cent,  to  9.5  per  cent,  of  the  human  race  have 
been  at  some  period  of  life  the  subject  of  tuberculous  infection,  as  demon- 
strated by  autopsy  findings,  and  that  only  mic  pci:  (in  in  seven  ,succuml.)s 
to  the  disease,  was  indicative  of  a  local  ti>-iic  k  i-i.-mcc,  alTmdini;  ])re- 
sumptive  evidence  of  a  general  tendency-  nf  the  c)rii:i.uisni  to  withstand 
advancing  infection.  Clinical  experience  has  demonstrated  from  time  to 
time  an  increased  resistance  to  infection  accompanying  the  development 
of  localized  tuberculous  proces.ses,  a  remarkable  inhibitory  influence  upon 
the  progress  of  pulmonary  phthisis  sometimes  being  noted  undci-  tliese 
circum-stances.  I  recall  several  instances  of  tuberculous  in\  (il\cnicnt 
of  joints,  bones,  glands,  kidne.ys.  andepicUdymis,  andparticnhuly  rases  of 
spinal  caries,  with  the  onset  of  which,  there  was  exhibited  an  immediate 
and  continuous  retrogression  in  the  activity  of  the  pulmonary  di.sease. 
This  coincidence  has  been  so  frequent  as  to  admit  of  no  doubt  concerning 
the  increased  general  resistance  often  accompanying,  if  not  occasioned 
by,  the  local  affection.     Such  cHnical  phenomena  are  strictly  in  accord 


732  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

with  Wright's  doctrine,  as  to  the  stimulated  machinery  of  self-immuniza- 
tion by  the  entrance  into  the  circulation  of  a  not  undue  amount  of  the 
toxins  emanating  from  the  site  of  local  infection. 

The  protective  influence  resulting  from  injecting  attenuated  cultures 
of  various  forms  of  bacteria  was  recognized  by  Pasteur  in  1879,  and  con- 
stituted the  first  important  advance  toward  the  experimental  production 
of  biologic  immunity.  The  well-known  doctrine  of  phagocytosis,  promul- 
gated by  Metchnikoff  in  1882.  related  to  the  conflict  between  the  invad- 
ing parasites  and  the  army  of  defense  composed  of  leukocytes.  The  role 
of  the  latter  was  supposed  to  consist  of  the  attack  upon  foreign  elements, 
and  their  subsequent  inglobement  and  digestion.  It  was  eonceivetl  1)}" 
Metchnikoff  that  there  "existed  in  certain  sera,  substances  capable  of 
enhancing  the  phagocytic  powers  of  the  leukocytes.  To  these  substances 
the  term  "stimulins^'  has  been  applied.  Phagocytosis  is  known  to 
vary  in  accordance  with  the  existence  of  cellidar  attraction  or  repulsion. 
This  theory  of  chemotaxis.  evolved  by  Pfeffer,  the  botanist,  was  extended 
by  j\Ietchnikoff  to  apply  to  his  hypothesis  concerning  the  phagocytic 
power  of  the  white  cells.  The  presence,  respectively,  of  a  positive  or 
negative  chemotaxis  as  a  determining  factor  in  the  production  of  phago- 
cytosis, was  resourcefully  accepted  by  Metchnikoff  to  be  a  fundamental 
principle  of  his  doctrine,  a  positive  chemotaxis  being  assumed  as  a 
basic  condition  for  the  formation  of  phagocytosis. 

Other  theories  of  immunity  have  subsequently  been  advocated,  and 
much  experimental  e\"idence  presented  to  establish  their  correctness. 
Some  of  these  appear  inherently  opposed  to  the  doctrine  of  phagoc3'tosis, 
some  capable  of  a  reconcilable  interpretation  with  this  theory,  and  others 
of  an  entirely  independent  relation.  It  is  impossible,  in  this  connection, 
to  cUscuss  the  theory  of  Ehrlich,  the  demonstrator  of  the  mechanism  of 
antitoxins,  of  Behring  and  Pfeiffer,  the  discoverers,  respectively,  of  anti- 
toxin and  the  bacteriolytic  action  of  immune  blood-serum,  nor  of  Gruber 
and  Widal,  the  orginators  of  the  agglutination  tests.  All  point  to  the  irre- 
sistible conclusion  that  the  human  body  possesses  means  of  defense  other 
than  obtain  alone  from  the  phagocytic  action  of  the  leukocytes.  Ehrlich 
advanced  the  theory  of  a  biologic  union  of  the  liacterial  toxins  and  the 
receptor  cells  of  the  individual,  as  an  essential  condition  of  actual  tox- 
emia. As  a  result  of  this  union  of  the  haptophores.  the  reaction  takes 
place  in  the  affected  receptor  cells,  which  are  stimulated  to  make  an 
excess  of  similar  groups,  constituting  agents  of  defense  and  called  anti- 
toxins. Unfortunately,  the  practical  application  of  the  principles  of 
antitoxic  immunity  in  pulmonary  tuberculosis  are  unsatisfactory  on 
account  of  the  insolubility  of  the  toxins  in  the  blood.  The  tubercle 
bacilli  and  other  pathogenic  bacteria  commonly  present  in  tuberculosis 
retain  their  toxin,  or  more  properly  endotoxin,  closely  inwrapped  within 
the  protoplasmic  body. 

In  this  connection  the  work  of  Pfeiffer,  with  reference  to  bacteriolytic 
action,  is  of  considerable  interest.  Bacteriolysis  is  thought  to  be 
attended  in  some  instances  with  such  a  liberation  of  the  endotoxin,  that 
the  disintegration  of  the  bacilli  may  not  only  afford  no  protection  against 
the  toxin,  but  possibly  may  even  increase  systemic  intoxication.  The 
tubercle  bacillus  has  been  found  to  respond  to  no  bactericidal  or  bacterio- 
l3i;ic  action  of  the  blood,  and.  generally  .speaking,  to  no  antitoxic  influ- 
ence, after  the  manner  of  diphtheria  and  tetanus.  In  the  light  of  recent 
investigations,  it  is  apparent  that  in  tuberculosis,  phagocytosis  still 


THEORIES    OF    IMMUNITY  733 

remains  a  most  important  element  in  the  production  of  immunity.  The 
degree  of  phagocytosis,  however,  is  dependent  upon  conditions  other 
than  the  simple  presence  of  a  positive  chemotaxis.  Substances  are 
known  to  exist  in  the  blood  which  exert  a  predominant  influence  upon 
the  phagocytic  action  of  the  leukocytes.  I'his  power  of  defense  by  the 
organism  is  found  to  vary  according  to  the  effect  of  certain  preparatory 
substances  upon  the  bacilli,  increasmg  their  susceptibility  to  the  action 
of  the  white  cells.  According  to  Potter,  the  earliest  demonstration  of 
an  increased  phagocytosis  referable  to  alterations  of  the  microorganism, 
was  made  by  Denys  and  Leclef  in  1895.  This  was  followetl  by  consider- 
able experimental  work  by  Bordet,  Mennes  and  Leishman,  Wright  and 
Douglass,  Neufeld  and  Rimpau,  Bullock,  Western,  Ruediger,  Saw- 
tchenko,  Dean,  and  Hektoen.  All  a.tcrecil  :is  to  the  specific  effect  of  the 
serum  upon  the  microorganism  and  its  c.-^scutiul  role  in  the  production 
of  phagocytosis.  Potter  has  reccnti\-  shown  that  the  phagocyting 
power  of  corpuscles  taken  from  a  di chsimI  person  is  considerably  less 
than  that  of  corpuscles  from  a  suppn.-cdl y  healthy  individual.  Thus,  in 
addition  to  the  differences  in  nornidl  srrd,  rariations  are  found  in  the 
phagocytic  activity  of  leukocytes  of  patients  subjected  to  bacterial 
infection  and  individuals  apparently  well.  Potter  has  suggested,  as  a 
result  of  his  observations,  that  during  a  severe  infection,  the  phagocytic 
power  is  disproportionately  lower  than  the  opsonic  index  of  the  serum, 
and  upon  recovery  the  defensive  activity  of  the  leukocytes,  in  compari- 
son with  the  corpuscles  of  normal  individuals,  enhanced  more  noticeably 
than  the  opsonic  power. 

The  term  "  opsonin' '  has  been  applied  by  Wright  to  the  substance 
preparing  the  microorganisms  for  phagocytosis.  As  mentioned  pre- 
viously, there  are  other  elements  involved  in  the  mechanism  of  immu- 
nity, i.  e.,  the  agglutinins,  the  bactericidal  substances,  the  bacterio- 
lysins,  and  the  antitoxins.  In  recognition  of  the  action  attributed 
to  these  substances,  all  may  be  grouped  under  the  term  "  bacteriotro- 
phins."  Wright,  modifying  the  nomenclature  of  Ehrlich,  speaks  of 
the  products  of  immunity  generally  as  antitropic  elements  or  antitropins. 
The  source  of  the  opsonins  in  the  blood  is  unexplained,  but  Wright 
believes  that  they  are  stimulated  locally,  hence  the  expechency  in  tuber- 
culous glands  and  lupus,  of  injecting  vaccines  near  the  site  of  infected 
processes.  Hektoen  and  Ruecliger,  in  1906,  showed  that  a  lytic  action 
without  opsonic  power  can  exist  in  normal  serum  and  vice  versa.  They 
also  showed  that  immunization  may  be  attended  by  opsonic  action 
without  agglutination  or  bacteriolysis. 

It  has  been  claimed  by  Wright  and  his  school  that  a  separate 
opsonin  exists  in  the  blood  for  each  variety  of  microorganism.  An 
elaborate  and  technical  method  for  the  precise  determination  of  the 
opsonic  power  of  chfferent  individuals  at  varying  times  in  relation 
to  the  several  forms  of  bacterial  invasion  has  been  advanced  by 
Wright.  The  amount  of  opsonins  present  to  combat  a  single  infec- 
tion may  be  widely  at  variance  with  the  extent  of  opsonic  action 
against  other  bacteria.  Further,  the  quantity  of  opsonic  substance 
within  the  blood  is  known  to  vary  considerably  in  the  same  individual 
from  time  to  time  under  differing  conditions.  These  conditions  relate 
not  only  to  external  factors,  such  as  exercise,  excitement,  food,  etc., 
but  also  to  varying  changes  within  the  body.  In  other  words,  there 
is  going  on  at  different  times  a  distinct  effort  on  the  part  of  the 


734  PROPHYLAXIS,    GENERAL    AND    SPECIFIC   TREATMENT 

organism  toward  self-immunization,  which  process  is  subject  to  remark- 
able fluctuation  in  accordance  with  certain  pathologic  and  physiologic 
conditions.  In  accordance  with  the  law  of  biologic  immunity,  when 
bacteria  or  their  poisons  are  introduced  into  the  system,  the  response 
of  the  organism  consists  of  the  elaboration  of  protective  substances 
against  these  invaders.  The  mechanism  of  defense  relates  to  the  action 
of  agglutinins,  lysins,  bactericidal  substances,  antitoxins,  and  opsonins. 
Under  soTne.  circumstances  the  tuberculous  individual  develops  resources 
of  tlefense  unattained  by  those  not  thus  affected,  antl  in  other  instances 
awaits  artificial  aid  to  immobilize  a  waiting  army  of  defense.  It  may  Ije 
that  even  an  excess  of  poisons  exists  in  the  body  to  start  the  machinery 
of  immunization,  but  is  incapable  of  utilization  by  virtue  of  being  locked 
up  within  foci  of  infection  by  heightened  bacteriotrophic  pressure.  Thus 
artificial  excitation  of  the  protective  processes  remains  to  be  secured  by 
the  introduction  of  bacterial  agents.  In  other  cases  an  overproduction 
of  poisons  emanating  from  centers  of  infection  is  attended  by  a  dimin- 
ished opsonic  power.  It  is  thus  apparent  that  the  maximum  amoimt 
of  opsonins  is  to  be  acciuired  neither  from  a  paucity  nor  a  surplus  of 
toxins,  but  rather  from  such  a  tlosage  at  different  times  as  will  supply 
the  deficit  in  the  working  capital  of  the  individual,  whose  unaided 
resources  of  a  toxic  nature  are  insufficient  for  the  maintenance  of  sat- 
isfactory immunization. 

In  some  chronic  infections,  where  a  lowered  bacteriotrophic  pressure 
continuoush'  prevails,  Wright  is  of  the  opinion  that  the  introduction  of  a 
suitable  \;iitiu(' act  s  as  :i  St  inuilHut  to  the  dormant  processes  of  immimity. 
The  oiisiiiiius  aic  oil  ell  sulijcct  lo  much  variation,  according  to  the  inflow 
into  the  cirrulation  of  the  liai-terial  products,  whether  they  are  present 
during  the  course  of  the  disease  or  are  introduced  for  therapeutic  pur- 
poses. In  tuberculosis  the  inflow  of  tuberculo-opsonic  substance  is  by 
no  means  constant.  Some  patients  are  continuously  overinfecting  them- 
selves from  numerous  foci,  and  others  persistently  suffering  from  defi- 
cient stimulating  toxins.  Wright's  practice  consists  of  an  attempted 
regulation  or  adjustment  of  the  amount  of  protective  poisons  b}'  means 
of  carefully  estimated  and  properlj'  interspersed  doses  of  artificial  \af- 
cines,  based  upon  the  frequent  estimate  of  the  op.sonic  power.  He  has 
demonstrated  a  certain  definite  sequence  of  changes  in  the  opsonic 
action  after  the  injection  of  vaccines.  Following  this  injection  there 
is  induced  a  phase  in  which  the  protective  substances  in  the  blooii.  opso- 
nins, agglutinins,  etc.,  are  diminished — the  so-called  negative  phase. 
This  is  followed  after  a  longer  or  shorter  period  of  time,  according  to  the 
size  of  the  injection,  by  a  rise  in  the  amount  of  protective  substances — 
the  so-called  positive  phase.  During  this  time  phagocytosis  is  markedly 
stimulated.  This  cyclic  variation  in  the  amount  of  protective  sub- 
stance in  the  blood  is  termed  "the  law  of  ebb  and  flow  and  reflow,  and 
the  maintained  high  tide  of  immunity." 

Successful  results  of  inoculation  depend  greatly  upon  the  adaptation 
of  the  size  of  the  dose  to  the  needs  and  requirements  of  the  general  organ- 
ism. The  excursion  of  the  negative  and  positive  phases  is  dependent  not 
only  upon  the  quantity  of  vaccine  introduced,  but  also  upon  the  original 
amount  of  opsonins  present.  Thus  a  small  do.se  in  case  of  a  relatively 
high  opsonic  power,  may  produce  but  slight,  if  any,  negative  phase,  and 
a  correspondingly  insignificant  positive  reaction.  A  similar  clo.se,  given 
in  the  presence  of  a  much  diminished  opsonic  power,  may  be  followed 


THEORIES    OF    IMMUNITY  735 

by  a  more  pronounced  negative  disturbance,  and,  up  to  a  certain  point, 
a  proportionately  greater  positive  phase.  If,  however,  a  large  amount 
of  toxin  be  injected,  the  negative  phase  may  appi'oach  to  a  condition  of 
collapse  and  be  attended  by  severe  constitutional  disturbance,  per- 
sisting for  a  prolonged  period  and  not  followed  liy  any  positive  phase 
whatever.  It  will  be  seen  that  the  very  essence  of  the  method  consists 
of  an  approximately  accurate  estimate  of  the  deficit  in  opsonic  resources, 
and  the  effort  to  supplant  the  natural  protective  forces  by  carefully 
adjusted  artificial  dosage.  By  injudicious  injections  the  natural  forces 
of  defense  may  be  supplantecl  altogether,  thus  destroying,  by  artificial 
means,  the  very  efforts  toward  self-protection.  With  diminished  resist- 
ance through  continuous  indiscreet  inoculations,  a  large  dose  admin- 
istered during  the  negative  phase  or  at  the  time  of  low  opsonic  power, 
may  culminate  in  such  depletion  of  protective  elements  as  to  overwhelm 
the  individual. 

By  the  use  of  suitalily  prepared  vaccines  the  bacteria  within  the 
system  are  rendered  more  .•^uscei)til)le  to  phagocytosis.  The  vaccine  in 
all  cases  of  bacillary  invasion  sa\-e  that  of  tuberculosis  should  be  pre- 
pared from  the  particular  strain  of  bacterial  infection  present  in  the 
individual  to  whom  it  is  to  be  administered.  It  is  probable  that  in 
tulierculous  affections  the  best  results  may  be  attained  by  the  use  of 
homologous  vaccines. 

In  case  of  pure  tuberculous  infection  without  constitutional  or  bac- 
teriologic  evidence  of  secondary  invasion  by  a  variety  of  pathogenic 
bacteria,  the  toxic  agent  ,ni'iii'raHy  ciiiiilnycd  for  practical  therapeutic 
purposes  is  Koch's  l.iaiilli  I'lnul mn.  ihc  new  tuberculin.  In  the  event 
of  mixed  infection  in  puliii(Hi;ir\-  t  iiliciculo.-i-.  with  considerable  temper- 
ature elevation  it  is  often  inexpedient  to  attempt  an  increase  of  the 
^M6ercM/o-opsonic  power  on  account  of  the  fluctuating  toxic  infection, 
which  precludes  any  effort  in  the  way  of  artificial  adjustment.  In 
such  cases  I  have  sometimes  been  able  to  secure  satisfactory  results  by 
the  use  of  homologous  vaccines.  Clinical  observations  of  this  nature 
will  be  later  reported.  The  vaccine  directed  toward  the  relief  of  the 
secondary  infection  is  i)l)t;iinc(l  from  the  sputum  of  each  invalid  for 
whom  the  agent  is  to  be  ciiiplDX  (m1. 

The  technic  of  this  prejKuatidu,  as  performed  by  Dr.  W.  C.  Mitchell, 
according  to  Wright's  methoil,  is  as  follows: 

After  sterilization  of  the  mouth  and  throat  with  a  saturated  solution  of  boric 
acid,  the  sputum  is  deposited  directly  from  the  mouth  into  a  sterilized  bottle.  A 
portion  of  the  sputum  is  separated  from  the  interior  of  the  mass  and  carefully  teased 
in  a  sterile  Petri  dish  with  sterile  forceps  or  platinum  loops.  This  rnass  is  rubbed 
upon  the  surface  of  a  blood-serum  culture-medium  and  the  process  continued  through 
a  series  of  five  or  six  test-tubes,  the  loop  being  sterilized  between  each  inoculation. 
After  subjection  to  a  temperature  of  .37°  C.  in  the  incubator  for  one  or  two  days,  the 
various  isolated  colonies  of  bacteria  are  recognized  in  the  fourth  or  fifth  tub^.  From 
these  tubes  they  may  be  separated  into  individual  cultures  liy  transference  to  other 
tubes  of  culture-media  and  incubated.  After  thus  securing  pure  cultures  of  the 
microorganism,  the  culture  is  scraped  with  a  glass  rod  or  a  platinurn  loop  into  a 
small  amount  of  sterile  salt  solution,  making  a  bacterial  emulsion.  This  is  placed  m 
a  sterile  test-tube  which  is  drawn  out  to  a  fine  point  and  sealed.  I-t  is  then  shaken 
for  fifteen  minutes  in  order  to  break  up  the  clumps.  To  dctcnniiv  the  slriiii;tli  of 
the  preparation  one  volume  of  blood  from  the  finger  is  mixed  with  :iii  ri|ii:il  i|u,in- 
tity  o'  the  above  bacterial  emulsion,  and  diluted  with  three  voluni.-  ni  iinriii;il  ^alt 
solution.  After  smearing,  fixing,  and  staining  the  ratio  of  niiircii>ri.':iiii-i]i>  to  the 
red  blood-cells  is  computed  from  the  study  of  a  number  of  fields.  The  examiner 
is  enabled  to  determine  the  number  of  bacilli  in  a  unit  of  volume  by  the  known 


736  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

number  of  red  cells  in  a  cubic  millimeter.  Thus  the  proportion  is  as  follows:  The 
number  of  red  blood-cells  in  a  given  number  of  fields  is  to  the  number  of  bacilli  in 
the  same  number  of  fields  as  5.500,000  red  blood-cells  (Colorado  altitude)  is  to  X. 
X  equals  tlie  number  of  bacilli  in  a  cubic  millimeter.  From  this  the  number  of 
bacteria  in  a  cubic  centimeter  is  obtained  by  multiplying  the  number  in  a  cubic 
millimeter  by  1000.  The  test-tube  containing  the  bacterial  emulsion  is  again  sealed 
and  placed  in  the  hot-water  bath  at  60"-02°  C.  for  one  hour.  It  is  necessary  to 
destroy  the  vitality  of  the  microorganisms  but  to  preserve  at  the  same  time  their 
toxic  properties.  Too  short  a  period  of  sterilization  will  fail  to  kill  the  bacteria, 
while  if  this  is  too  prolonged  the  preparation  will  be  rendered  inert.  After  the 
process  of  sterilization  is  completed  the  bacterial  emulsion  is  diluted  with  sterile  salt 
solution,  and  a  computation  made  of  the  number  of  bacteria  in  each  cubic  centi- 
meter. Control  cultures  are  made  in  all  cases  to  demonstrate  that  the  vitality  of 
the  bacteria  is  actually  destroyed.  The  tubercle  bacilli  vaccine,  in  contradistinction 
to  the  above,  is  estimated  by  weight  rather  than  by  enumeration,  and  is  given  in 
initial  doses  of  from  one  ten-thousandth  to  one  one-thousandth  of  a  milligram. 

The  determination  of  the  opsonic  power  of  an  individual  consists  of  an  estimate 
of  the  relative  number  of  bacteria  ingested  by  washed  white  blood-cells  under  the 
influence  of  the  patient's  serum,  in  comparison  with  the  number  ingested  by  the 
same  number  of  cells  in  the  presence  of  normal  blood-serum  under  precisely  similar 
conditions.  It  follows,  therefore,  that  as  essential  factors  there  must  be  blood  from 
the  patient ;  blood  assumed  to  be  normal :  and  washed  leukocytes.  In  addition,  there 
must  be  at  hand  an  emulsion  of  the  sporific  hartrria  concerning  which  the  opsonic 
action  is  sought.  After  cleansing  of  tin  fiii;;'  r  tin'  patient's  blood  is  withdrawn  by 
means  of  capillary  attraction  into  the  cm  \  r.l  cm  ninity  of  a  glass  capsule, the  fine 
capillary  ends  of  which  have  been  broken.  The  st  rai<cht  end  of  the  capsule  is  sealed 
by  holding  in  a  mildly  burning  flame.  It  is  important  to  have  the  flame  hot  enough 
to  seal  the  end  of  the  tube  quickly,  in  order  to  avoid  heating  that  portion  of  the  cap- 
sule containing  the  blood  and  thus  modifying  the  opsonic  power.  If  the  straight 
end  of  the  capsule  is  not  too  short,  the  bulging  portion  wherein  the  blood  is  to  be 
shaken  from  the  curved  extremity  is  not  likely  to  be  heated  by  the  sealing  of  the 
other  end.  Should  this  take  place,  a  portion  of  the  blood  is  forced  from  the  curved 
end  by  the  expanding  air  within  the  tube.  The  blood  is  to  be  shaken  from  the  curved 
extremity  into  the  bSging  jxirtion.  Pouring  of  cold  water  upon  the  distal  or  straight 
end  produces  such  contraction  of  air  as  to  draw  the  blood  quickly  beyond  the  elbow. 
The  normal  or  control  blood  is  obtained  in  the  same  manner.  The  two  capsules, 
after  identification  marking,  are  allowed  to  clot  and  are  then  centrifuged  in  order  to 
separate  the  serum.  The  ends  of  the  capsule  are  broken  and  the  serum  is  ready  for 
extraction  with  a  fine  pipet. 

The  washed  leukocytes  are  prepared  as  follows  :  About  twenty  large  drops  of 
blood  are  placed  in  several  times  this  volume  of  normal  salt  solution,  containing  1.5 
per  cent,  of  sodium  citrate.  After  thorough  «nixing  and  centrifuging  the  superna- 
tant liquid  is  aspirated  with  a  fine  pipet.  Normal  (85)  per  cent,  salt  solution  is 
added  to  the  corpuscles  to  remove  traces  of  serum.  The  process  of  centrifuging  is 
repeated,  and  the  supernatant  liquid  again  separated.  Thus  the  serum  is  removed 
and  the  blood-cells  remain  in  the  bottom  of  the  tube,  the  leukocytes  forming  the 
superficial  layer  or  cream.  To  produce  the  bacterial  emulsion  the  cultures  are  diluted 
with  a  small  amount  of  salt  solution  until  a  milky  appearance  is  secured,  and  are 
centrifuged  in  a  small  tube  to  throw  down  the  clumps. 

A  commercial  product  of  tubercle  baciUi  emulsion  may  be  secured  containing  a 
suspension  of  bacilli  in  glycerin.  This  is  washed  off  by  salt  solution,  filtered,  and 
the  residue  ground  with  0.5  per  cent,  salt  solution  until  a  milky  emulsion  is  produced. 
The  essential  constituent  factors  are  now  ready  for  utilization.  Fine  capillary  pipets, 
made  after  the  direction  of  Wright,  with  an  even  caliber,  are  marked  in  such  a  way 
as  to  designate  a  fixed  volume  or  unit  of  measure.  An  equal  volume  of  washed 
leukocytes,  patient's  serum,  and  bacilli  emulsion  are  withdrawn  into  the  same  pipet 
and  deposited  upon  a  sterile  slide  for  the  purpose  of  more  thorough  mixing.  The 
combined  liquid  once  more  is  drawn  into  the  pipet  which  is  sealed  and  placed  in  the 
opsonic  incubator  for  fifteen  minutes  at  a  temperature  of  ,37°  C.  An  identical  proc- 
ess is  pursued  with  the  normal  blood.  After  the  incubation  period  is  finished  a  film 
or  smear  is  prepared  in  each  instance  upon  a  slide  in  such  a  manner  as  to  insure  even 
distribution.  'The  specimen  is  now  ready  for  staining,  carbol-fuchsin  being  used  for 
tubercle  bacilli  and  the  so-called  Leishman  stain,  consisting  of  eosin  and  methylene- 
blue,  for  nearly  all  others.  In  lieu  of  Leishman's  stain  the  specimen  may  be  fixed 
with  a  saturated  solution  of  corrosive  sublimate  and  stained  with  thionin  or  any 
suitable  anilin  dye. 


THEORIES    OF    IMMUNITY  t  ,i  i 

After  selecting  a  proper  field  with  the  low  power  the  oil-immersion 
lens  is  used  to  count  the  numl)er  of  microorganisms  found  in  each  of 
50  to  100  polymorphonuclear  neutropliiles.  The  average  number  of 
the  bacteria  contained  in  the  whole  number  of  cells  counted,  consti- 
tutes the  phagocytic  index.  This,  for  the  normal  blood,  is  regarded 
as  unity,  though  some  variation  exists  among  health}-  individuals. 
The  phagocytic  index  of  the  patient  as  compared  with  that  of  a 
healthy  individual  gives  the  opsonic  index.  Thus,  if  the  average 
number  of  bacteria  contained  within  a  given  number  of  normal  blood- 
cells  is  eight,  and  the  number  in  the  blood  of  the  patient  is  four, 
based  upon  the  count  of  an  equal  number  of  cells,  the  opsonic  index 
would  be  one-half  that  of  the  normal  and  would  be  expressed  as  0.5. 

The  opsonic  index,  as  previously  stated,  is  subject  to  considerable 
variation  in  different  individuals  suffering  from  the  same  disease,  and 
in  the  same  person  accorcUng  to  the  degree  of  systemic  infection,  and  as 
claimed  by  some  according  to  certain  exteruul  conditions,  as  exercise 
or  excitement.  If  the  index  of  any  ,ui\cii  niici'iKirganism  is  continu- 
ously low,  it  is  assumed  that  there  exists  u  localized  focus  of  bacillary 
invasion.  If  the  index  is  high  above  unity,  di'  if  a  derided  fluctuation  is 
found  in  succes.sive  examinations,  the  eviilcmc  puiiit--  to  a  pronounced 
systemic  infection.  It  is  suggested,  therefcue,  thai  repeated  observa- 
tions of  the  opsonic  index  should  possess  a  considerable  degree  of 
diagnostic  merit,  and  afford  approximate  indications  with  reference  to 
vaccine  therapy. 

There  has  been  much  convincing  testimony  jiresontod  by  Wright  and 
his  followers  concerning  the  practical  utilit>'  o(  his  met  hod  of  attempted 
artificial  immunization.  The  general  consensus  ul'  djuuion  among  scien- 
tists and  clinicians  is  to  the  effect  that  mcrinr  medication  is  founded 
upon  rational  grounds  and  is  destined  tn  lejuesent  a  great  advance  in 
the  therapy  of  the  future.  The  jirirlsr  ni/uldlion  of  the  dosage,  based 
upon  the  determination  of  the  opsonic  index,  however,  is  ojien  to  con- 
troversy. Adverse  opinions  are  freely  expressed  iimceruiim  the  general 
impracticability  of  his  work,  on  the  score  of  the  iiiaii\  opportunities  for 
error  and  confusion  in  the  detailed  ajijiliratioii  of  the  iiiiii<'ate  terhnic. 
In  addition  to  the  dilliculiie.-  aHeiiiliiii:  the  lecliiiic,  due  eounizauce 
should  be  taken  of  the  pos-ilih>  sources  ol  enoi'  iidierelit  to  dijjir,  nccs 
in  the  susceptibilit!/  of  tlie  microorgauisni.s  lo  agglutination  in  a  com- 
paratively large  volume  of  serum,  and  to  the  variations  in  the  effect 
of  the  pathologic  sera  upon  normal  phagocytes.  It  does  not  follow, 
however,  that  ifor  these  reasons  alone  the  method  of  Wright  is  unworthy 
of  recourse  by  those  qualified,  through  training  and  equipment,  to  take 
advantage  of  his  contributions. 

Wright  and  Bullock  have  called  attention  to  one  of  the  difficulties 
in  securing  immunization  in  pulnioiiai\-  t  ul>erculosis  from  the  em- 
ployment of  tuberculin.  They  atfrilnite  eousulerable  importance  to 
the  histologic  and  pathologic  struct  me  ot  the  pulmonary  tubercle  as 
offering  a  barrier  to  the  antil>ariei  iai  forces  of  the  organism.  They 
believe  that  the  toxins,  otherwise  simulating  to  the  machinery  of  immu- 
nization, are  locked  up  within  these  foci  of  infection,  and,  per  contra, 
if  artificial  aids  to  the  immunizing  process  are  introduced  into  the  cir- 
culation, that  the  bacilli  remain  protected  to  some  extent  behind  a  wall 
of  non-vascular  connective  tissue.  It  thus  appears  that  inoculations 
with  bacilli  emulsion  are  regarded  as  dangerous  for  one  class  of  consump- 


738  PROPHYLAXIS,    GENERAL    A.ND    SPECIFIC    TREATMENT 

lives  suffering  from  an  excess  of  toxins,  and  as  non-e^cctive  on  account 
of  structural  conditions  for  those  exhibiting  a  deficiency  of  these  pro- 
tective substances.  This  hypothesis  of  the  defense  of  the  bacillus  is 
opposed  to  usually  accepted  ideas  concerning  the  inclosure  of  the  bacil- 
lus, its  possible  exclusion  from  the  organism  as  a  result  of  encapsula- 
tion, and  the  protection  accruing  to  the  individual  by  this  means.  The 
theory  of  Theobald  Smith  as  to  the  defensive  role  of  the  celkdar  out- 
lying breastworks  in  the  interests  of  the  bacillus  containetl  within  its 
tubercle  abode,  is  somewhat  in  accord  with  that  of  Wright,  although 
inspired  by  no  acceptance  of  a  special  relation  of  opsonins  or  blood  leuko- 
c}-tes  to  immunity.  He  regards  the  tissue  reaction  concernetl  in  the 
process  of  tubercle  formation  as  an  important  element  in  the  mechan- 
ism of  defense,  both  for  the  host  and  the  parasite.  Thus  a  quiescent 
focus  is  secured  for  the  indefinite  and  undisturbed  sojourn  of  the  bacil- 
lus, but  opportunities  at  the  same  time  are  denied  for  its  multiplica- 
tion or  escape.  He  also  advances  the  theory,  as  previously  stateil,  that 
the  bacilli  are  at  times  pro\ided  with  a  protective  envelope,  which  he 
believes,  in  contradistinction  to  Wright's  hypothesis,  to  remain  intact 
when  the  opsonic  power  is  low,  and  thus  exert  a  protective  influence  upon 
the  organism  by  preventing  multiplication.  An  apparent  immunitj'^ 
is  supposed  to  exist  at  such  a  time,  to  be  succeeded  Iny  removal  of  the 
envelope,  multiplication  of  bacilli,  and  greater  tuberculous  activitj-  in 
proportion  as  the  opsonic  power  is  elevated.  It  would  seem,  in  the 
midst  of  conflicting  views  entertained  bj'  many  eminent  authorities, 
that  general  clinical  observations  should  lie  worthy  of  presentation. 


CHAPTER   C 


PERSONAL  OBSERVATIONS  UPON  THE  USE  OF 
BACTERIAL  VACCINES' 

The  published  reports  of  Wright  and  his  fellow-workers  indicate 
the  value  of  vaccine  medication  in  localized  tuberculous  infections  of 
the  bones,  joints,  glands,  and  portions  of  the  genito-urinary  tract,  but 
suggest  that  the  results  of  its  emploj'ment  in  pidmonary  tuberculosis 
are  likely  to  be  disappointing.  He  recognizes  elements  of  danger  if 
the  bacilli  emulsion  is  administered  indiscriminately  to  pulmonary 
invalids,  and  particularly  in  the  presence  of  fever  and  a  widel}-  fluctu- 
ating index-curve.  Under  such  conditions  the  patient  is  already  under- 
going a  continuous  infection  from  an  improperly  adjusted  and  inter- 
spersed dosage  of  the  toxins.  At  such  a  time  the  employment  of  the 
vaccine  only  adds  to  the  burden  of  the  individual,  and  diminishes  any 
effort  on  the  part  of  the  organism  toward  autoimmunization.  This 
objection  to  the  use  of  the  vaccine  in  pulmonary  tuberculosis,  obtains  in 
the  event  of  an  existing  surplus  in  the  blood  of  toxins  emanating  from 
tuberculous  foci,  and  as  well  from  centers  of  secondary  injection.     The 

'  A  portion  of  this  chapter  was  written  for  the  annual  meeting  of  the  American 
Climatological  Association,  held  in  Washington,  May,  1907,  but  was  not  reatl,  owing 
to  unavoidable  absence.  A  supplement arj"  report  is  appended,  embracing  the 
results  of  subsequent  observation. 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL   VACCINES      739 

thought  naturally  arises  whether  the  existence  of  a  severe  mixed  infec- 
tion in  pulmonary  tuberculosis  materially  alters  the  indications  for 
tuberculin,  or  suggests  the  expediency  of  resorting  to  an  autogenetic 
vaccine. 

It  is  very  essential  to  establish  somewhat  definitely  if  vaccine 
medication  is  of  clinical  value  in  pulmonary  tuberculosis,  and  to  what 
extent  its  employment  should  be  based  upon  the  determination  of  the 
opsonic  index. 

In  view  of  the  unreliability  of  the  serum  preparations  sometimes  em- 
ployed to  combat  the  mixed  infection  of  pulmonary  tuberculosis,  and  the 
many  disadvantages  attending  their  use,  1  was  actuated,  in  the  early  part 
of  1907,  to  institute  a  clinical  inquiry  concerning  the  results  possible  of 
attainment  with  the  bacterial  vaccines.  It  was  also  my  purpose  to  deter- 
mine, if  possible,  the  effect  of  the  bacilli  emulsion  upon  cases  of  pulmo- 
nary tuberculosis  uncomplicated  by  mixed  infection.  It  was  recognized 
that  a  purely  scientific  investigation  along  these  lines  would  involve  such 
frequent  estimates  of  the  opsonic  index  as  to  be  prohibitive  of  the  obser- 
vation of  more  than  a  few  cases.  In  view  of  the  supposed  range  of 
variation  in  the  indices  of  many  pulmonary  invalids,  it  was  felt  that 
approximately  correct  conclusions  from  an  opsonic  or  laboratory  stand- 
point would  demand  the  observations  of  the  index  once  daily.  I  did 
not  feel,  however,  that  the  scope  of  my  investigation  should  relate 
merely  to  the  recording  of  indices,  and  the  assumption  of  an  increased 
power  of  resistance  in  a  very  few  closely  observed  cases,  but  rather  to 
the  clinical  stud[/  of  a  comparatively  large  number  of  patients  conforming 
to  the  same  general  class.  This  has  necessitated  the  taking  of  the  index 
of  each  patient  at  quite  infrequent  intervals.  A  degree  of  compensation 
for  this  discrepancy  has  been  secured  by  the  careful  selection  of  cases, 
and  the  fact  that  the  patients  were  kept  under  the  closest  practicable 
supervision  in  order  to  avoid  diurnal  fluctuations  of  the  index  from 
external  causes.  I  beg  to  express  my  obligation  to  Dr.  W.  C.  Mitchell 
for  his  careful  performance  of  the  technical  portion  of  the  work,  includ- 
ing the  determination  of  the  opsonic  indices  and  the  preparation  of  the 
bacterial  vaccines.  An  appreciative  recognition  is  also  accorded  Dr.  E. 
W.  Emery  for  valuable  assistance  rendered  in  the  opsonic  work.  In  all 
instances  the  index  was  secured  prior  to  the  first  dose,  and  thereafter  at 
intervals  of  from  ten  days  to  a  few  weeks.  In  the  beginning  an  effort 
was  made  to  take  the  indices  more  frequently,  but  this  practice  was 
discontinued  for  several  reasons.  The  e\'ident  futility  of  such  spas- 
modic efforts  to  obtain  an  approxiin.-itc  csiimate  of  the  mean  daily 
opsonic  power  was  apparent.  In  \ic\v  uf  ihr  lai'ge  number  of  patients 
undergoing  vaccine  treatment,  frequent  olisiMN'ation  of  the  indices  was 
impossible.  The  increased  financial  burtlcu  incident  tn  their  oft-repeated 
determination  represented  a  factor  of  cdii-ideialile  importance.  The 
clinical  study  was  undertaken  solely  for  practical  junposes,  and  despite 
its  deficiencies  resulted  in  an  instructive  experience. 

The  total  number  of  patients  undergoing  vaccine  therapy,  in  the 
first  four  months  of  1907  was  67,  who  were  divided  into  three  widely 
differing  groups.  In  work  of  this  character  a  proper  classification  of 
cases  constitutes  a  feature  of  the  utmost  importance. 

Group  1  comprised  42  cases  of  chronic  pulmonary  tuberculosis 
without  symptoms  referable  to  mixed  infection.  It  was  recognized 
that  all  patients  should  represent,  if  possible,  the  same  general  type  and 


740  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

stage  of  the  disease,  and  conform  more  or  less  closely  to  a  fixed  regime. 
It  seemed  highly  desirable  that  there  should  be  eliminated  all  sources 
of  confusion  arising  from  climatic  influence  or  change  of  environment. 
To  this  end  patients  included  in  this  ^luup  \\(>ie  selected  with  extreme 
care.  In  view  of  the  uncertainties  .ii  icn.liui;  its  employment,  no  indi- 
vidual was  permitted  to  undergo  the  ticat incut,  whose  general  condition 
and  previous  progress  had  been  entirely  satisfactory,  or  who  exhibited 
appreciable  temperature  elevation.  On  the  other  hand,  an  effort  was 
made  in  the  selection  of  cases  to  include  onl}-  those  who,  in  spite  of  a 
continued  residence  in  Colorado  xitidi  r  (ipiirdjirintc  ronditions  of  daily  life, 
had  failed  to  secure  an  entire  arro.-t  ol  the  tuliciculcjus  process.  It  was 
believed  that  more  definite  infornuuiim  rouicnuuii  the  effect  of  the 
treatment,  coidd  be  secured  by  limiting  its  api^lication  to  those  whose 
condition  had  been  almost  stationary  for  prolonged  periods.  Of  all  the 
eases  comprising  this  group,  the  average  period  of  residence  in  Colorado, 
with  practically  unchanged  environment,  was  two  years  and  eleven 
months,  the  longest  being  ten  and  one-half  years  and  the  shortest  six 
months.  A  remaining  activity  of  the  tuberculous  process  was  present 
in  all  cases,  as  evidenced  by  physical  signs,  cough,  expectoration,  and 
bacilli.  A  new  method  of  treatment  was  hailed  with  enthusiasm  by 
these  patients  as  precursory  of  possil^le  future  recover^-,  thus  introduc- 
ing a  psychic  element  impossible  of  elimination.  The  injections  were 
administered  at  regular  intervals  of  two  weeks.  This  periocUcity  of 
dosage  was  decided  upon  in  order  to  conform  as  far  as  possible  to  the 
expected  expiration  of  the  positive  phase.  The  initial  dose  was  usually 
one  ten-thousandth  of  a  milligram.  Both  a  low  and  high  index  were 
considered  suggestive  of  a  small  dose  in  the  beginning. 

It  was  noted  that  the  initial  opsonic  index  of  several  patients,  upon 
the  basis  of  Wright's  conclusions,  suggested  a  «o?i-tuberculous  concUtion. 
The  variation  in  health  is  supposecl  to  range  from  0.8  to  1.2.  Wright 
has  assumed  that  any  persisting  deviation  from  these  limits  is  fairly 
indicative  of  a  bacterial  invasion,  and  has  regarded  a  normal  index  as 
suggestive  of  its  probable  exclusion.  As  a  matter  of  fact,  in  this 
series  many  patients  exhibiting  a  normal  index  were  individuals  cUs- 
playing  pronounced  physical  and  subjective  evidences  of  advanced 
tuberculous  change.  There  was  shown  a  wide  range  in  the  opsonic 
index,  even  among  a  group  of  patients  especially  selected  with  a  view 
to  securing  approximate  uniformity  of  conditions.  It  may  be  stated 
parenthetically  that  the  subsequent  clinical  results  in  a  few  patients 
with  high  indices,  indicated  their  favorable  response  to  the  tuberculin 
injections,  quite  as  much  as  in  others  with  a  beginning  low  opsonic 
power.  During  the  entire  period  of  observation  a  disparitii  was  noted 
between  the  clinical  and  opsonic  findings.  Many  patients  disj^laying 
conspicuous  improvement  as  a  result  of  the  tuberculin  injections  were 
found  to  exhibit  trifling  variations  in  the  opsonic  index.  Upon  the  other 
hand,  several  whose  index  curve  was  found  to  undergo  a  satisfactory 
elevation,  nevertheless  failed  to  respond  favorably  to  the  specific  medi- 
cation. The  early  discrepanc}'  between  the  clinical  and  opsonic  results 
suggested  that  the  lack  of  parallelism,  occasioned  presumably  by  rea- 
son of  the  difficult  and  intricate  technic  was  sufficient  to  vitiate  any 
practical  deductions  based  upon  the  observation  of  the  index.  It 
soon  became  questionable  if  any  reliable  information  was  furnished  by 
the  opsonic  index  either  concerning  the  clinical  progress  or  the  size 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   741 

and  frequency  of  dosage.  In  the  light  of  these  investigations  it  was 
later  decided  to  discontinue  the  study  of  the  indices,  but  to  pursue  the 
inquiry  along  the  lines  of  clinical  observation.  Although  especial  inter- 
est attaches  to  the  individual  cases,  the  clinical  results  may  be  gener- 
alized briefly.  In  no  instance  have  I  been  able  to  detect  permanent 
injury  from  the  treatment,  and  in  some  cases  conspicuous  improve- 
ment. Although  demonstrable  progress  has  been  established  in  many 
instances,  it  is  probable  that  in  some  cases  the  psychic  element  has  been 
a  factor  of  con.siderable  importance.  It  is  noteworthy,  however,  that 
not  infrequently  depression  of  spirits  has  ensued  for  one  or  two  days 
following  the  injection,  several  complaining  of  phy.sical  weakness,  lassi- 
tude, and  .slight  indisposition.  Some  have  exhibited  a  rise  of  tempera- 
ture of  one  or  two  degrees,  beginning  a  few  hours  after  the  injection  and 
persisting  during  the  next  day.  In  a  few  instances  there  has  been  a 
slight  chill,  followed  by  fever,  and  in  two  patients  a  severe  rigor.  In 
one  case  a  sharp  hemorrhage  took  place  within  a  few  hours,  but  ceased 
abruptly  and  was  not  followed  by  recurrences.  Two  others  experienced 
a  slight  hemorrhage  of  very  short  duration.  A  number  have  complained 
of  headache,  this  being  severe  in  but  two  cases,  one  of  which  was  relieved 
by  calcium  lactate.  In  some  instances  there  has  been  temporary 
exacerbation  of  cough  and  expectoration. 

It  is  apparent  from  these  manifestations,  that  the  agent  is  not  always 
unattended  by  local  and  constitutional  reaction,  but  the  unpleasant 
symptoms  are  almost  uniformly  of  short  duration  and  relatively  infre- 
quent. Upon  the  other  hand,  there  has  beeir  several  times  an  admission 
of  a  material  diminution  of  cougli,  and  sometimes  its  complete  cessa- 
tion. The  sputum  has  been  markedly  lessened  in  many  cases.  In  a 
few  instances  a  conspicuous  diminution  of  l)acilli  has  been  noted  several 
months  after  the  inauguration  of  this  treatment.  A  gain  in  weight  has 
been  exhibited  by  several  patients  whose  previous  efforts  in  this  direction 
had  proved  unavailing.  In  no  case  has  there  been  a  loss  of  nutrition. 
A  better  appreciation  of  the  character  of  results  reasonably  to  be 
expected  from  time  to  time  among  cases  of  this  character,  is  afforded  by 
a  brief  history  of  a  few  special  cases. 

Case  1. — An  army  officer,  thirty-three  years  of  age,  consulted  me 
November  20,  1905,  immediately  upon  arrival  in  Colorado,  eighteen 
months  after  the  development  of  his  initial  tuberculous  trouble.  During 
a  six  months'  sojourn  in  New  Mexico,  he  experienced  several  hemor- 
rhages without  appreciable  change  in  the  general  condition.  There 
was  some  temperature  elevation  daily,  and  considerable  dyspnea  upon 
exertion.  There  were  extensive  areas  of  active  infection  in  each  lung, 
moist  rales  being  recognized  upon  the  right  side  from  the  apex  to  the 
fourth  rib,  and  to  the  lower  edge  of  the  shoulder-blade;  on  the  left  to 
the  fifth  rib,  and  to  the  very  base  behind.  During  the  following  year  he 
exhibited  a  pronounced  improvement  in  many  rospprts.  establishing  a 
gain  of  nearly  forty  pounds  in  weight,  with  corrcs]i<iiiiliii,ii  increase  of 
strength  and  absence  of  fever.  In  January,  1907,  despite  ;ui  apparent 
amelioration  of  the  activity  of  the  tuberculous  proceiss,  as  indicated  by 
physical  signs,  there  remained  persisting  cough  with  copious  expecto- 
ration. Perhaps  the  most  striking  feature  of  his  case  at  that  time 
was  the  enormous  number  of  bacilli  in  the  expectoration.  It  was 
determined  to  employ  specific  medication,  and  the  bacilli  emulsion 
was  administered  on  January  6th.     The  initial  dose  was  one  ten-thou- 


742  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

sandth  of  a  milligram.  No  symptoms  distinctly  referable  to  this  injec- 
tion were  displayed,  although  the  patient  volunteered  the  information, 
after  a  few  days,  that  the  cough  and  expectoration  were  appreciably 
reduced.  The" second  dose  of  tubercidin  was  oue-four-thousaudth  of 
a  milligram,  which,  like  the  preceding,  was  unattended  by  pronounced 
symptoms,  although  a  subsequent  diminution  of  the  expectoration  was 
vouched  for  by  the  patient  and  nurse.  The  third  injection  consisted 
of  one  two-thousandth  of  a  milligram,  the  dose  subsequently  being 
gradually  increased  until  one  five-hundredth  of  a  milligram  was  taken 
at  fortnightly  intervals.  There  has  taken  place  a  material  diminution 
of  cough  and  expectoration,  together  with  a  gratifying  increase  of 
strength  and  endurance. 

During  the  six  months  following  this  report,  the  improvement  was 
continuous,  the  most  conspicuous  features  being  the  further  abatement 
of  the  cough,  with  entire  absence  of  its  former  paroxysmal  character, 
the  comparatively  scanty  expectoration,  the  improved  nutrition,  and 
the  increased  general  vitality. 

Case  2. — A  woman  of  twenty-five  j^ears  arrived  in  Colorado  April, 
1897,  several  months  after  the " de\elopment  of  a  rapidly  progressing 
pulmonary  tuberculosis.  There  was  a  loss  of  twenty-six  pounds  in 
weight,  with  excessive  cough  and  expectoration,  acceleration  of  pulse, 
and  moderate  fever.  She  came  under  my  observation  four  months 
later,  having  suffered  further  loss  of  weight  and  strength.  There  was 
extensive  tuberculous  involvement  of  the  left  lung,  as  evidenced  by 
signs  of  consolidation,  with  moist  rales  upon  easj-  respiration  from  the 
apex  to  the  base  in  front,  and  to  the  lower  angle  of  the  scapula.  In 
January,  1907,  she  had  been  under  my  care  during  nine  and  one-half 
years,  having  shown  varying  periods  of  improvement  and  retrogression. 
During  the  past  few  years,  however,  despite  the  continuous  enforce- 
ment of  a  strict  supervisory  control,  there  had  been  noted  but  slight, 
if  any.  tendency  toward  improvement,  although  at  one  time  there  had 
been  established  a  gain  of  thirty-two  pounds  in  weight.  During  1906 
the  progi-ess  of  the  case  had  been  distinctly  downward,  the  patient 
having  lost  twenty-one  pounds,  and  exhibiting  marked  increase  of  cough 
and  expectoration,  in  connection  with  renewed  activity  of  the  tuber- 
culous process.  Cavity  formation  developed  in  the  upper  portion  of  the 
left  lung,  with  extension  of  the  tuberculous  infection  to  the  right  side 
from  the  apex  to  the  third  rib.  While  bacilli  were  exceedingly  numer- 
ous, there  was  but  slight  temperature  elevation.  The  bacilli  emulsion 
was  administered  .January  14th.  The  first  injection  was  followed  by  no 
distinct  symptoms,  but  a  few  hours  after  the  second  dose,  which  was 
one  one-thousandth  of  a  milligram,  there  was  a  sharp  chill,  with  a  later 
temperature  elevation  of  103°  F.,  which  persisted  for  two  days.  There 
has  been  no  fever  or  other  unpleasant  manifestations  attending  succeed- 
ing doses.  An  improvement  in  the  cough  and  expectoration,  which 
was  noted  several  days  after  the  second  injection,  has  since  been  main- 
tained until  both  have  become  quite  insignificant.  She  has  gained 
fifteen  pounds  in  weight,  and  correspondingly  in  strength.  Exami- 
nation of  the  chest  discloses  a  perceptible  diminution  in  the  amount  of 
moisture.  Despite  the  clinical  evidences  of  improvement,  the  opsonic 
index  has  shown  an  exceedingly  slight  variation,  two  points  being  the 
extreme  in  any  instance,  and  the  last  index  being  preciseh'  the  same 
as  that  observed  before  the  remedy  was  administered. 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   /43 

The  gain  thus  accruing  from  the  employment  of  tuberculin  during 
a  period  of  four  months  has  been  considerably  augmented  during  the 
remainder  of  the  year.  The  cough  and  expectoration  remain  very 
slight.  The  weight  has  further  increased  ten  pounds,  and  the  general 
Strength  promoted  to  a  surprising  degree.  At  no  previous  time  during 
a  residence  of  ten  years  in  Colorado  has  the  patient  enjoyed  an  excellent 
appetite,  with  almost  entire  disappearance  of  couali  and  expectoration. 
While,  generally  speaking,  it  is  well  understodd  tlmi  no  accurate  con- 
clusions are  justified  upon  the  basis  of  the  number  (if  bacilli,  some  sig- 
nificance, nevertheless,  maj'  be  attached  to  the  fact  that  they  are  much 
less  numerous  than  formerly.     (See  radiograph,  Fig.  54.) 

Case  3. — A  man,  twenty-three  years  old,  came  to  Colorado  in 
October,  1905,  two  years  and  three  months  after  t lie  development 
of  pulmonary  tuberculosis,  a  considerable  poitidu  (if  which  time  had 
been  spent  in  an  eastern  sanatorium.  A  progressixc  decline  had  been 
exhibited,  with  distressing  cough  and  profuse  expectoration.  There 
was  an  average  temperature  elevation  of  one  degree  daily,  the  pulse 
ranging  from  110  to  120.  The  temperament  was  nervous,  and  the 
patient  was  depressed  and  apprehensive.  There  was  extensive  tuber- 
culous infection  of  both  lungs.  Upon  the  left  side  signs  of  consolidation 
were  recognized,  with  loud  bubbling  rales  from  apex  to  base,  front  and 
back,  and  in  the  right  lung,  moist  rales,  without  consolidation,  from  apex 
to  base  in  the  back.  The  patient  remained  in  the  recumbent  position 
in  the  open  air  for  one  year  and  three  months  a  trained  nurse  being  in 
constant  attendance.  A  gain  of  ten  pounds  was  secured,  but  no  percep- 
tible improvement  was  noted  in  the  condition  of  the  lungs.  In  the 
beginning  of  1907,  the  sputum  was  excessive  and  loaded  with  tubercle 
bacilli.  The  bacilli  emulsion  was  given  January  10th.  A  noticeable 
improvement  has  been  secured,  as  shown  by  increase  of  strength  and 
weight,  diminution  of  cough  and  expectoration,  and  a  pronounced 
change  for  the  better  in  tlie  )>li\  ,-i(  :il  signs. 

During  the  en.^uiiiL!  i\  immhiIi^  the  patient  gained  an  adcUtional 
fifteen  pounds  in  \vei,i;hi.  wiih  rorre.sponding  improvement  in  the 
general  condition.  There  is  an  almost  entire  absence  of  cough  and 
expectoration,  and  a  complete  disappearance  of  tubercle  bacilli.  The 
physical  signs,  however,  do  not  denote  an  entire  arrest  of  the  tubercu- 
lous process.  Evidences  of  moisture  are  no  longer  recognized  in  the 
right  lung,  but  very  fine  clicks  are  detected  after  a  cough  in  the  upper 
portion  of  the  left  back.     (See  Fig.  60.) 

Cose  4.— A  woman  of  thiit y-tliree  couMilted  nie  Febniaiy  17,  1905, 
two  years  after  arrival  in  Cdloradn.  and  Um-  year-  aiiei  ilie  dexelop- 
ment  of  her  pulmonary  tulieicuhisis,  diuinii  wlinh  (iiiie  ^lie  liad  \isited 
various  health  resorts.  The  general  trentl  of  the  case  hax'ing  been 
downward  from  the  beginning,  she  was  advised  by  her  medical  attendant 
to  return  home.  Cough  was  severe,  expectoration  copious,  the  tempera- 
ture elevated  daily,  and  dyspnea  marked  upmi  sH^lii  exercise.  She 
came  under  my  care  at  this  time,  showing  extciiMvc  a<  ii\e  tuberculous 
involvement  of  both  lungs.  Upon  the  left  side  iheie  was  extensive 
consolidation,  with  coarse  bubbling  rales  to  the  fifth  rib  and  to  the  mid- 
dle of  the  interscapular  space,  and  upon  the  right,  moist  rales,  without 
consolidation,  to  the  third  rib  and  to  the  spine  of  the  scapula.  During 
a  period  of  one  year  and  eleven  months  up  to  January,  1907,  she  exhibited 
remarkable  progress,  gaining  forty  pounds  in  weight,  with  correspond- 


744  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

ing  improvement  in  strength  and  in  the  condition  of  the  lungs.  The 
cough  and  expectoration,  however,  remained  but  little  affected.  Tu- 
bercle bacilli,  though  not  numerous,  were  recognized  in  every  micro- 
scopic field.  Injections  of  bacilli  emulsion  were  commenced  on  January 
10th.  Like  the  preceding  case,  a  very  perceptible  gain  has  been  noted 
throughout  the  entire  period  of  administration. 

The  improvement  has  been  maintained  continuously,  the  cough  and 
expectoration  being  greatly  reduced.  Tubercle  bacilli  are  absent  alto- 
gether in  some  specimens,  and  in  others  found  only  after  long  search- 
ing.    (See  Fig.  83.) 

Case  5. — A  woman,  aged  twenty-three,  developed  tuberculosis  in 
March,  1905,  and  after  spending  nine  months  in  Las  Vegas,  New  Mexico, 
came  to  Colorado  with  active  extensive  tubercidous  infection  of  each 
lung.  There  was  a  loss  of  fifteen  pounds  in  weight,  moderate  fever, 
weak  and  rapid  pulse,  nervous  temperament,  paroxysmal  cough,  and 
exces.5ive  expectoration.  There  were  signs  of  consolidation  in  each 
upper  lung,  with  moist  rales  on  the  left  side,  from  the  apex  to  the 
fourth  rib  and  to  the  lower  angle  of  the  scapula;  upon  the  right,  from 
the  apex  to  the  third  rib  and  to  the  middle  of  the  scapula.  During 
the  summer  and  fall  of  1906  a  pronounced  gain  was  established,  the 
weight  increasing  twenty-five  pounds.  The  upward  progress  apparently 
reached  a  standstill  early  in  1907,  the  physical  signs  being  practically 
the  same  as  upon  arrival,  and  the  cough  and  expectoration  not  espe- 
cially diminished.  The  tuberculin  treatment  was  instituted  January 
24th.  A  material  subsidence  of  the  cough  and  expectoration  was  estab- 
lished after  a  few  injections,  together  with  a  distinct  improvement  in 
the  physical  signs,  the  opsonic  intlex,  however,  showing  scarcely  any 
variation. 

An  examination  of  this  patient,  made  January  6,  1908,  showed  no 
evidence  of  tuberculous  trouble  in  one  lung,  and  a  very  slight  amount  of 
moisture  in  the  apex  of  the  other.  Several  examinations  of  the  sputum 
have  failed  to  disclose  the  presence  of  bacilli  during  the  past  few  months. 
(See  Fig.  65.) 

Case  6. — A  woman  of  twenty-three  sought  climatic  change  m 
October,  1900,  exhibiting  active  tubercidous  involvement  of  both  lungs 
of  six  months'  duration.  There  was  pronounced  loss  of  weight  and 
strength.  The  examination  of  the  chest  revealed  well-defined  con- 
solidation at  the  right  apex,  with  bubbling  rales  to  the  third  rib  and 
middle  of  the  interscapular  space.  Upon  the  left  side  moisture  was 
readily  detected  from  the  apex  to  the  spine  of  the  scapula.  The  progress 
of  the  case  up  to  January,  1907,  could  not  be  regarded  as  satisfactory. 
The  cough  and  expectoration  showed  but  little  abatement.  There 
were  daily  elevations  of  temperature,  decided  impairment  of  appetite, 
and  continued  activity  of  the  tul)erculous  process,  as  evidenced  by 
numerous  bacilli  and  persisting  moisture  in  the  finer  bronchi.  Through- 
out an  entire  year  (1906)  the  patient  suffered  almost  continuously  with 
severe  pleuritic  pains  in  the  right  side,  with  frequent  .slight  hemopty.ses. 
The  tuberculin  was  given  in  January,  1907,  and  upon  the  following  day 
there  was  a  severe  rigor,  followed  by  a  sharp  elevation  of  temperature, 
which  persisted  for  two  days,  with  noticeable  aggravation  of  cough.  In 
sub.sequent  doses  of  one  four  thousandth  of  a  milligram  the  patient  has 
experienced  slight  malaise  and  inchsposition  for  one  day,  without  other 
disagreeable  manifestations.     A  material  improvement   has  been  ex- 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL    VACCINES       745 

hibited  in  the  general  condition  and  physical  signs,  without  appreciable 
variation  in  the  opsonic  index.  At  no  time  since  beginning  the  adminis- 
tration of  the  vaccine,  have  the  pleuritic  pains  been  felt  or  has  the 
slightest  trace  of  blood  appeared  in  the  sputum. 

The  improvement  in  the  physical  condition  has  been  pronounced. 
At  present  the  physical  sip;ns  in  the  loft  lunc;  arc  entirely  negative.  Upon 
the  right  side,  while  the  cNidciiccs  uf  the  (vuIn  cousnlidation  in  the  upper 
portion  still  persist,  but  :iu  cxci'i'dinjily  .^li^lu  uiuount  of  moisture  can 
be  recognized  upon  careful  examination.  Very  line  clicks  are  detected 
in  a  small  circumscribed  area  below  the  clavicle,  and  at  the  very  apex 
behind.  The  general  condition  is  excellent,  although  the  cough  and 
expectoration  have  not  entirely  disappeared  and  bacilli  are  present  in 
small  numbers. 

Case  7. — A  woman,  twenty-four  years  old,  arrived  in  Denver  dur- 
ing the  summer  of  1906,  after  having  suffered  from  pulmonary  tuber- 
culosis during  a  period  of  three  and  one-half  years.  There  was  a 
loss  of  twenty  pounds  in  weight,  moderate  cough  without  fever,  an 
excellent  appetite  and  digestion.  There  existed  marked  consolida- 
tion of  the  left  upper  front  to  the  third  rib  and  to  the  middle  of 
the  scapula.  Moist  rales  were  recognized  to  the  fourth  rib  in  front 
and  to  the  base  behind.  Upon  the  right  side  there  were  moist  i-ales 
to  the  second  rib  and  to  the  upper  angle  of  the  scapula.  Bacilli 
were  present  in  large  numbers.  During  the  succeeding  six  months 
not  the  slightest  improvement  was  exhibited  in  spite  of  favorable 
surroundings  and  implicit  obedience  to  detailed  instructions.  There 
resulted  a  loss  of  seven  pounds  in  weight,  a  diminution  of  strength, 
increase  of  cough  and  expectoration,  without  fever.  In  view  of  the 
absence  of  fever  and  the  unmistakable  evidences  of  progressive  decline, 
it  was  determined,  for  experimental  purposes,  to  administer  the  tuber- 
culin in  spite  of  a  relatively  high  opsonic  power.  The  first  dose  was 
given  on  January  20th,  and  continued  with  regularity  every  two  weeks. 
While  no  disagreeable  symptoms  resulted  from  its  administration,  no 
appreciable  improvement  was  noted  during  the  first  six  weeks.  There 
developed  subsequently  a  gratifying  change  for  the  better,  as  evidenced 
by  great  diminution  of  cough  and  expectoration,  a  gain  in  weight,  and 
increase  of  strength,  with  lessened  activity  of  the  tuberculous  process. 
The  bacilli  were  decidedly  less  numerous  in  the  sputum. 

During  the  latter  part  of  1907  the  patient  evinced  a  remarkable 
improvement  in  all  respects.  The  examination  of  the  chest  revealed  an 
entire  absence  of  moisture,  while  the  cough  and  expectoration  almost 
disappeared.     (See  radiograph.  Fig.  64.) 

Case  S. — This  case  is  somewhat  similar  to  the  preceding  in  many 
respects.  A  woman  of  forty-six  came  under  my  observation  in  August, 
1903,  after  residing  in  Colorado  two  years,  and  exhibiting  a  progressive 
decline  from  the  onset  of  her  tuberculous  infection.  On  account  of 
emaciation  and  extreme  prostration,  with  high  fever  daily,  diarrhea, 
distressing  cough,  and  advanced  tuberculous  change  in  the  lungs,  the 
patient  had  been  advised  by  her  physician  to  return  home.  During 
the  following  two  years  she  gained  thirty  pounds  in  weight  and  exhibited 
definite  evidence  of  improvement  in  the  general  condition  and  in  the 
pulmonary  process.  After  many  months'  confinement  in  bed  as  a  re- 
sult of  a  .series  of  severe  hemorrhages,  she  lost  twenty  pounds  in  weight, 
and  exhibited  during  the  following  year  but  slight  recuperative  power. 


746  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

As  a  probable  result  of  the  tuberculin  inoculations,  the  cough  and 
expectoration  materially  diminished  and  a  pronounced  improvement 
was  noted  in  the  general  strength.  The  bacilli  were  considerably  less 
numerous  than  before  the  injections  were  given,  but  the  tuberculo- 
opsonic  index  remained  unchanged. 

An  examination  of  the  patient  upon  January  5,  1908,  shows  an  entire 
arrest  of  the  tuberculous  process  in  the  right  lung,  with  extensive  fibrosis. 
But  very  fine  semidry  clicks  are  recognized  after  cough  at  the  very  apex 
of  the  left  lung.  The  cough  and  expectoration  are  relatively  slight, 
while  the  bacteriologic  findings  are  absolutely  negative.     (See  Fig.  61.) 

Case  9. — A  woman  of  twent.v -seven  considted  me  in  July,  1904,  eight 
months  after  arrival  in  Colorado  and  five  jears  following  the  develop- 
ment of  her  tuberculous  infection.  There  was  a  loss  of  fifty  pounds  in 
weight,  daily  afternoon  temperature  of  101  °  to  102°  F.,  marked  dyspnea, 
and  prostration.  There  was  slight  consolidation,  with  moist  rales  in  the 
left  lung  from  apex  to  base,  and  upon  the  right  side  to  the  third  rib. 
As  a  result  of  a  continuous  conformity  to  a  systematic  regime,  a  slow 
but  progressive  improvement  has  taken  place.  In  January,  1907,  she 
had  gained  fifteen  pounds  in  weight  and  materially  in  strength.  The 
physical  signs  remained,  however,  practically  unchanged.  Cough  was 
frequent  and  distressing,  and  expectoration  profuse.  Shortly  after 
beginning  the  injections  of  bacilli  emulsion  there  took  place  a  pro- 
nounced improvement  in  all  respects.  The  cough  and  expectoration 
have  almost  ceased.  There  is  a  gain  in  the  general  condition  and  a 
perceptible  diminution  in  the  number  of  bacilli. 

The  patient  was  permitted  to  return  home  during  the  summer  of 
1907,  and  I  am  informed  that  no  retrogression  has  taken  place.  (See 
Fig.  68.) 

Case  10. — A  man,  forty-one  years  old,  came  under  my  observation 
in  September.  1904.  nine  months  after  the  onset  of  pidmonary  tuber- 
culosis. There  were  much  emaciation  and  physical  weakness,  a  daily 
temperature  elevation  of  two  or  three  degrees,  and  distressing  cough. 
The  tuberculous  process  was  extensive  and  active  in  each  lung.  Upon 
the  right  side  there  was  consolidation  with  moist  rales  to  the  third  rib 
and  to  the  very  base  behind.  An  appreciable  consolidation  was  recog- 
nized upon  the  left  side,  in  the  upper  front,  with  slight  moisture,  while 
in  the  back  there  were  coarse  rales  from  the  apex  to  the  lower  angle  of 
scapula.  Up  to  the  fall  of  1906  there  was  exhibited  a  decided  improve- 
ment in  all  respects,  the  cough  and  expectoration  tlisappearing  altogether, 
the  weight  becoming  greatly  increased,  with  no  longer  evidence  of  active 
involvement  upon  physical  examination.  This  case  was  reported  a 
year  ago  as  an  instance  of  an  apparent  total  arrest  of  the  tuberculous 
process,  although  previously  adjudged  to  have  been  utterly  hopeless. 
After  returning  home  and  engaging  again  in  an  arduous  career,  he 
returned  to  Colorado  in  the  spring  of  1907,  exhibiting  a  loss  of  twenty 
pounds  in  weight  and  renewed  activity  of  the  tuberculous  process  with 
numerous  bacilli  in  the  expectoration.  After  three  or  four  doses  of 
tuberculin  were  given  there  took  place  a  moderate  le.ssening  of  the  cough 
and  expectoration,  with  a  corresponding  diminution  in  the  number  of 
tubercle  bacilli. 

After  a  summer  in  the  mountains  of  Colorado,  during  which  further 
improvement  was  attained,  the  patient  again  returned  to  his  home  and 
resumed  the  duties  incident  to  his  profession.     1  am  informed  that  a 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   747 

further  gain  in  weight  has  been  secured,  that  the  cough  and  expectora- 
tion are  very  slight,  the  former  strength  and  endurance  but  little 
impaired,  although  a  few  bacilli  are  occasionally  detected  in  the  sputum. 
(See  Fig.  81.) 

The  foregoing  cases  have  been  selected  as  illustrative  of  the  beneficial 
influence  undoubtedly  exerted  by  the  bacilli  emulsion.  The  conclusion 
seems  unavoidable  that  this  agent  has  been  responsible  in  large  measure 
for  the  improvement  noted. 

Of  the  remaining  32  cases  in  this  class,  15  may  be  said  to  have 
exhibited  some  favorable  effect  from  the  administration  of  the  remedy. 
In  12  there  was  no  appreciable  influence  properly  attributable  to 
the  tubercidin.  Five  exhibited  an  increase  of  cough  and  expectora- 
tion after  each  injection,  to  such  an  extent  that  the  tuberculin  was 
suspended  after  three  or  four  doses.  It  is  noteworthy  that  no  patient 
with  high  initial  tuberculo-opsonic  index,  even  though  much  in  excess 
of  normal,  failed  to  respond  favorably  to  the  influence  of  the  remedy. 
The  diminution  of  bacilli  in  a  number  of  cases  is  reported  solely  as  a 
matter  of  interest,  with  due  regard  for  the  fact  that  this  observation 
is  of  doubtful  importance. 

Group  2  consists  of  ten  patients  who  had  resided  in  Colorado  for 
varying  periods  of  time,  but  whose  localized  tuberculous  processes  sug- 
gested the  advisability  of  this  treatment.  In  this  class  arc  included 
three  cases  of  tuberculous  cervical  glands,  one  of  tuberculosis  of  the 
sacral  and  lumlDar  \-ertebr8e,  with  discharging  sinus,  one  of  primary 
tuberculosis  of  the  larynx,  one  of  tuberculosis  of  the  pharynx,  one  of 
tuberculous  bronchitis,  two  cases  of  tuberculosis  of  the  testes,  and 
another  of  the  kidneys. 

The  case  of  lumbar  and  sacral  caries  with  discharging  sinus  was 
complicated  by  severe  mixed  infection,  and,  therefore,  will  he  described 
under  the  succeeding  group.  One  case  of  glandular  involvement  was 
not  under  observation  sufficiently  long  to  warrant  the  expression  of  a 
positive  opinion,  as  to  the  efficacy  of  the  treatment,  but  distinct  improve- 
ment was  noted  in  the  second  instance.  The  third  patient  with  gland- 
ular tuberculosis  had  suffered  a  return  nf  ihis  condition  after  several 
years'  disappearance  of  the  glands.  Idljowiui:,  a  prolonged  couise  of 
treatment  with  the  .r-ray.  On  accouiil  of  an  unsighth'  and  progressively 
enlarging  nevus  over  the  site  of  the  glands,  presumablj-  occasioned  by 
the  too  frequent  use  of  the  .r-ray,  further  recourse  to  this  agent  was 
impracticable  upon  the  reapjiearance  of  the  glandular  enlargement. 
Two  injections,  therefoi-c.  of  tuKeiriiliii  wpi-o  aihiiinistei-fd.  and  attended 
in  each  instance  by  a  -liar|i  Icm.iI  icai'tion,  without  other  ron>tiniiional 
disturbance  than  physical  weakness  and  iiiahiiso.  The  day  following 
the  second  dose  the  glamlular  mass  became  increased  in  size,  reddened, 
and  decidedly  painful.  The  external  appearance  was  that  of  acute 
inflammation.  In  view  of  the  pain  and  local  discomfort,  further  con- 
tinuance of  the  tuberculin  was  not  deemed  practicable.  On  account 
of  the  presence  of  the  nevus,  which  occasioned  considerable  disfigure- 
ment, it  was  decided  to  resort  to  surgical  methods  for  its  excision  and 
for  the  removal  of  the  glandular  enlargement. 

The  case  of  primary  tuberculosis  of  the  larynx  has  lieen  reported 
elsewhere.     (See  p.  526.) 

The  patient  was  referred  for  laryngologic  treatment  to  Dr.  Levy, 
who  rendered  a  guarded  prognosis.     The  patient  was  kept  under  treat- 


748  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

raent  for  two  months,  with  but  slight  resulting  improvement  either  in  the 
lociil  or  general  condition.  He  was  then  given  the  injections  of  bacilli 
emulsion  during  a  period  of  two  months,  from  which  an  improvement  in 
the  local  condition  was  reported. 

No  conclusion  of  value  could  be  drawn  from  the  administration  of 
the  remedy  to  the  patient  with  pharyngeal  tuberculosis  as  manifes- 
tations of  a  general  miliary  involvement  speedily  supervened. 

The  case  of  tulierc'ilosis  of  the  testes,  which  is  of  great  interest,  has 
been  described  under  Genito-urinary  Complications  upon  p.  509. 

Another  case  of  tuberculosis  of  both  testes  has  exhibited  an  appreci- 
able improvement  following  the  tuberculin  injections.  The  tuberculous 
involvement  upon  one  side  was  of  thirteen  months'  duration,  and  upon 
the  other  of  five  months,  the  patient  being  a  boy  of  nineteen  without 
pulmonary  involvement.  A  perceptible  diminution  of  the  discharge 
from  each  sinus  has  taken  place,  together  with  a  reduction  in  the  size 
of  the  tuberculous  organs. 

The  ca.se  of  tuberculosis  of  the  kidney  is  also  instructive.  The 
patient,  a  man  of  about  thirty-five  years  of  age,  came  under  my  obser- 
vation February  16,  1907,  being  referred  to  me  by  Dr.  Leonard  Free- 
man for  opinion  with  reference  to  the  advisability  of  nephrectomy.  The 
patient  had  been  under  his  care  since  November  1,  1906,  consulting  him 
at  that  time  on  account  of  a  perinephritic  abscess  of  the  left  side  of  ten 
days'  duration  following  a  cold.  The  urine  was  loaded  with  pus.  The 
abscess  was  opened  and  found  to  contain  a  foul,  thick,  purulent  secre- 
tion. The  kidney  was  easily  felt,  and  contained  several  small  superficial 
abscesses,  which  were  not  incised.  Subsequent  examinations  of  the 
urine  showed  no  tubercle  l^acilli,  but  numerous  colon  bacilli.  Inocula- 
tion into  the  peritoneal  cavity  of  a  guinea-pig  was  followed  by  innumer- 
able tuberculous  deposit:!  in  the  peritoneum  and  omentum.  The  urine 
was  turbid,  ropy,  and  .slightly  alkaline,  containing  a  large  amount  of 
albumin.  Macroscopic  pus  was  recognized  upon  standing.  There  were 
many  large  and  small  round-cells,  occasional  normal  blood-cells,  and  a 
few  leukocytes.  A  catheterized  specimen  of  urine  from  the  ureter  of 
the  opposite  side  contained  a  considerable  amount  of  albumin  and  a 
number  of  hyaline,  granular,  and  epithelial  casts.  Catheterized  speci- 
mens three  weeks  later  .showed  an  increased  amount  of  albumin  and 
casts.  Early  in  March  edema  of  the  feet  and  ankles  developed.  The 
general  condition  was  very  poor,  with  much  emaciation  and  weakness. 
The  urine  continued  to  contain  a  large  amount  of  albumin  and  macro- 
scopic pus,  with  occasional  normal  blood-cells.  The  state  of  the  general 
health  was  not  such  as  to  suggest  the  expediency  of  immediate  opera- 
tion. Owing  to  the  unquestionable  tuberculous  process  involving  one 
kidney,  and  an  irritative,  if  not  degenerative,  condition  in  the  other,  it 
was  thought  best  to  administer  the  tuberculin  temporarily  and  note 
results  with  reference  to  the  local  tuberculous  process  and  the  general 
condition.  The  bacilli  emulsion  was  administered  at  frequent  intervals 
during  a  period  of  four  weeks,  without  the  .slightest  evidence  of  resulting 
improvement.  In  .spite  of  the  desperate  condition  of  the  patient  and 
the  known  serious  involvement  of  l)Oth  kidneys,  I  advised  the  performance 
of  nephrectomy  on  the  ground  that  no  harm  could  possibly  result  from 
the  removal  of  a  large  focus  of  tuberculous  material.  The  operation 
was  performed  by  Dr.  Freeman.  A  fatty  tumor  the  size  of  the  fist 
was  found  to  form  a  part  of  the  kidney.     The  organ  was  disintegrated 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   749 

and  contained  several  abscesses,  as  well  as  a  stone  the  size  of  the  last 
joint  of  the  little  finger.  This  was  soft  and  easily  crushed.  The  patient 
did  exceedingly  well  for  some  months  following  the  removal  of  the 
kidney.  He  was  able  to  walk  about;  the  edema  of  the  extremities 
largely  disappeared,  and  the  urine  became  much  clearer,  though  con- 
taining some  pus  and  albumin,  occasional  large  and  small  round-cells, 
squamous  epithelial  cells,  but  no  blood  or  casts.  The  improvement, 
however,  was  temporary,  the  patient  succumbing  several  months  after 
the  operation. 

Group  3  comprises  an  entirely  (liffci'cut  cutcsioi'v  of  patients  from 
the  preceding  class,  as  it  embraces  ci.  cs  cvhilMiiuu  imt  (>\dy  advanced 
tuberculous  change,  but  also  profouml  const  it  uiioii;i,l  ili-.turli;uice  result- 
ing from  secondary  infection.  Xo  jiaiii  nt  hn.s  In  ,  n  iik-IikIkI  in  this  ijinup 
C07icerning  whom  th<:n  cimld  Ikut  lucn  <iili  iIhiiikI  nni/  niliiindl  hojir  of 
im-provement  other  than  ujkih  tlic  Imsi.s  ,,/  mi  nulij  (■(mini/  nj  Ih,  .-«  jilin  niia. 
Those  who  are  familiar  with  the  possible  disadvanta.iics  :iticii(liiii;  tlie 
employment  of  serum  preparations  in  this  condition,  ami  i licit-  ttucer- 
tainty  of  action,  can  well  understand  the  incentives  to  tc-i  the  cfiicacy 
of  a  bacterial  agent  capable  of  wider  application,  especially  if  unattended 
by  unfortunate  sequelae.  The  patients  in  this  group  number  15,  the 
opsonic  indices  for  the  particular  infection  varying  from  0.4  to  0.75. 
Upon  the  other  hand,  by  a  strange  coincidence,  the  tuberculo-opsonic 
index  was  almost  invarial^ly  high.  The  character  of  the  infection  was 
determined  liy  culture  methods  supplementary  to  microscopic  examina- 
tion. The  individual  vaccines  were  prepared  from  cultures  grown  from 
the  secretions  of  the  patient  to  whom  the  agent  was  to  be  given.  In  12 
cases  the  vaccine  was  derived  from  the  sputum,  in  1  case  from  a  cathe- 
terized  specimen  of  the  urine,  and  in  2  cases  from  a  discharging  sinus. 
The  predominant  mixed  infection  was  in  5  instances  st;i])li\l(ici)ccus 
aureus,  in  2  cases  staphylococcus  aureus  and  alhus,  in  1  case  stuijhylo- 
coccus  albus,  in  3  cases  streptococcus,  in  2  cases  pneumococcus,  in  1  case, 
colon  bacillus,  and  in  1,  micrococcus  catarrhalis. 

A  brief  generalizing  statement  of  results  is  perhaps  in  order  before 
submitting  the  detailecl  report  of  special  cases.  As  a  rule,  the  opsonic 
index  to  the  microorganism  constituting  the  secondary  infection,  did 
not  exhibit  the  violent  fluctuations  one  might  naturally  suppose  from 
so  severe  systemic  invasion.  On  the  other  hand,  the  tuberculo-opsonic 
index  was  higher  and  more  constant  than  had  been  expected.  In 
many  cases  this  remained  strangely  in  the  vicinity  of  normal,  in  which 
event  no  effort  was  made  to  increase  resistance  to  tuberculous  infection 
by  the  use  of  the  bacilli  emulsion.  In  other  cases,  after  the  amelio- 
ration of  the  systemic  infection,  the  patients  were  treated  by  occasional 
doses  of  the  new  tuberculin,  but  not  at  the  same  time  with  the  other 
bacterial  vaccines.  The  indices  were  not  taken  as  often  as  could  be 
desired,  but  were  observed  quite  as  frequently  as  was  practicable  under 
somewhat  difficult  circumstances.  Generally  speaking,  the  subsidence 
of  fever  and  chills  was  accompanied  by  an  elevation  of  the  index  for 
the  secondary  infection.  Some  cases,  however,  exhibited  periods  of 
improvement  which  were  not  associated  with  a  corresponding  change 
in  the  index.  Conversely,  others  exhibited  at  times  exacerbations  of 
fever,  the  relation  of  which  to  the  opsonic  power  it  was  difficult  to 
determine. 

In  clinical  observations  of  this  character  among  private  patients. 


750  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

involving  the  outlay  of  much  laborious  effort  in  connection  with  the 
technic,  and  hence  a  considerable  item  of  financial  expenditure,  it  is 
clearly  impossilJe  to  secure  as  much  opsonic  data  as  would  appear 
desirable  from  a  purely  scientific  standpoint.  From  a  clinical  aspect, 
however,  the  evidence  was  conclusive  that,  in  some  instances,  much 
good  resulted  from  the  employment  of  bacterial  vaccines.  The  unfa- 
vorable consequences  were  of  short  duration,  and  were  incident  to 
early  injudicious  dosage,  although  a  reliant  dependence  at  that  time 
was'  placed  upon  the  opsonic  findings.  Disturbing  symptoms  were 
subsequently  avoided  by  cautious  conservatism  in  this  respect.  In 
some  instances,  what  developed  to  be  a  disproportionately  large  dose  in 
conjunction  with  a  low  index,  prolonged  the  so-called  negative  phase 
for  a  number  of  days,  and  delayed  for  a  considerable  period  a  subsequent 
elevation  of  the  index.  The  imminent  danger  arising  from  such  a 
source  was  later  recognized,  and  a  painstaking  effort  was  made  to  regu- 
late the  size  and  frequency  of  the  dose,  not  by  the  opsonic  findings,  but 
by  the  character  of  the  present  and  prerious  clinical  man ilestat ions. 

In  view  of  the  desperate  condition  of  the  patients  and  the  dangerous 
possibilities  attaching  to  the  remedy,  it  is,  perhaps,  somewhat  remark- 
able that  serious  residts  were  not  encountered  by  one  previously  unac- 
customed to  work  of  this  nature.  No  patient  has  suffered  permanent 
injury,  although  in  some  instances  exacerbations  of  the  constitutional 
symptoms  have  taken  place.  The  nature  and  extent  of  the  residting 
disturbance  have  varied  with  the  character  of  the  bacterial  infection. 
Thus  the  employment  of  streptococcic  and  pneumococcic  vaccines  has 
been  followed  by  disagreeable  symptoms  oftener  than  injections  of 
staphylococcic  or  other  varieties.  Out  of  the  fifteen  cases,  all  but  three 
exhibited,  following  one  or  more  injections,  distinctly  unfavorable  symp- 
toms, one  exception  being  an  instance  of  infection  with  micrococcus  ca- 
tarrhalis,  another  with  the  staphylococcus  albus  from  a  discharging  sinus, 
and  the  third,  a  case  of  croupous  pneumonia.  In  the  remaining  cases, 
varying  degrees  of  chilliness  and  temperature  elevation  followed  at  least 
one  of  the  injections,  in  some  cases  the  disturbance  partaking  of  a  sharp 
rigor  and  residting  prostration.  In  the  majority  of  instances  a  severe 
reaction  has  occurred  but  once.  The  unpleasant  symptoms  have  some- 
times followed  the  first  injection,  though  more  frequently  observed  in 
connection  with  subsequent  doses,  which  were  gradually  increased 
according  to  the  tolerance  of  the  individual.  Many  patients  after  a 
single  unfortunate  experience,  exhibited  no  disagreeable  symptoms  from 
repeated  administrations  of  the  vaccine.  A  slight  elevation  of  temper- 
ature the  day  following  the  injection  was  quite  generally  observed. 
Favorable  results  were  rarely  noticed  until  the  second  or  third  da}',  and 
in  a  few  cases  did  not  persist  for  over  one  week  or  ten  days  before  a 
tendency  toward  retrogression  was  exhibited.  In  such  cases  renewed 
improvement  was  usually  noticed  a  few  days  after  each  succeeding  dose. 

The  residts  in  some  cases  have  been  uniquely  satisfactory,  while 
in  others  the  improvement  has  been  slow  and  .somewhat  disappointing. 
In  a  few  instances,  as  will  be  noted,  the  gain  has  been  quite  remarkable. 
Of  the  15  ca.ses,  12  are  reported  in  some  detail,  as  well  as  another  which 
was  observed  during  the  summer  of  1907.  Of  these  13  cases,  10 
exhil)ited  very  substantial  improvement.  The  condition  was  so  des- 
perate in  each  instance  anfl  the  improvement  so  conspicuous  as  to 
justify  an  assumption  concerning  the  efficacy  of  the  specific  treatment. 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   751 

In  8  of  these  cases  there  has  been  no  rcl  lo^ression  during  a  period  of  one 
year,  but  one  has  failed  to  maintain  ilu'  impiovement  previously  insti- 
tuted and  another  has  died  from  sudi  k'U  heiiKnihage.  In  the  3  remaining 
cases  the  patients  finally  succumbed,  although  apparently  responding 
favorably  to  the  vaccine  for  brief  temporary  periods.  In  order  to  afford 
some  approximate  idea  of  the  individual  results  obtained  in  this  group, 
a  brief  outline  of  a  few  illustrative  cases  will  be  reported. 

Case  21. — The  patient  was  a  woman,  fifty  years  old,  with  pulmonary 
tuberculosis  of  eleven  years'  duration,  the  onset  beginning  with  a  severe 
pneumonia,  which  confined  her  to  bed  during  nine  months.  There 
followed  a  persisting  paroxysmal  cough,  with  profuse  purulent  and, 
at  times,  fetid  expectoration.  Ten  years  ago  a  brisk  hemorrhage  took 
place,  followed  by  numerous  recurrences,  marked  loss  of  strength,  and 
fifty  pounds  in  weight.  During  this  entire  period  she  has  developed 
at  inter\als  a  pronounced  septic  condition.  In  January,  1907,  she  pre- 
sented the  history  of  ha\ing  suffered  daily  chilis  and  fever  during  the 
previous  two  or  three  months,  and  the  condition  was  one  of  extreme 
prostration.  The  examination  of  the  chest  disclosed  the  presence  of 
extensive  active  tuberculous  involvement  of  the  right  lung,  from  apex 
to  base,  with  considerable  cavity  formation,  together  with  a  more 
recent  inva.sion  of  the  left  lung  from  apex  to  fourth  rib  and  to  the  lower 
angle  of  the  scapula.  Throughout  these  regions  moist  bubbling  rales 
were  recognized.  Upon  the  right  side,  in  addition  to  the  massive 
consolidation  with  areas  of  softening  and  excavation,  there  existed  at 
the  base  aljsolute  flatness,  with  absence  of  breath-  and  voice-sounds, 
although  aspiration  performed  not  less  than  six  or  seven  times  was 
invariably  attended  by  a  negative  result.  Bacilli  were  very  numerous. 
The  mixed  infection  was  found  to  be  streptococcic  in  character.  The 
initial  streptococcic  opsonic  index  was  0.5,  and  the  tuberculo-op.sonic 
index,  1.8.  The  first  dose  of  streptococcic  vaccine  was  given  upon 
the  evening  of  January  6th.  The  preparation  was  so  standardized 
that  one  cubic  centimeter  represented  5,000,000  of  the  microorganisms. 
One-tenth  of  a  cubic  centimeter  was  administered.  Upon  the  following 
day  the  temperature  was  somewhat  higher  than  previously,  and  the 
general  disturbance  was  more  pronounced.  Upon  the  third  day  the 
temperature  dropped  to  normal,  where  it  remained  for  nearly  four 
weeks,  during  which  time  the  patient  gained  materially  in  strength, 
though  with  continued  copious  expectoration.  At  the  end  of  one 
week  the  streptococcic  opsonic  index  was  0.9,  showing  an  increase  of 
almost  one-half.  A  few  clays  later  the  tuberculo-opsonic  index  was 
1.9,  showing  a  rather  striking  similarity  to  the  previous  observation. 
Upon  January  26th  the  streptococcic  opsonic  index  was  0.8.  The 
vaccine  was  not  repeated  until  over  three  weeks  after  the  initial  dose, 
on  account  of  the. continued  improvement  in  the  general  health.  After 
the  exhibition  of  a  slight  chill  with  temperature  elevation,  the  remedy 
was  given  in  a  somewhat  larger  dose  than  first  administered.  This 
was  followed,  like  the  preceding  injection,  by  increased  fever  and  pros- 
tration for  one  or  two  days,  at  the  end  of  which,  the  temperature 
elevation  receded  and  a  renewed  improvement  took  place.  Since 
this  time  there  have  been  occasional  brief  periods  of  mild  temperature 
elevation  and  a  few  slight  chills.  The  vaccine  was  given  at  weekly 
intervals,  5,000,000  of  the  streptococci  being  administered  at  a  single 
injection  without  resulting  reaction.     For  several   months  there  was 


752  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

but  slight  elevation  of  temperature  at  any  portion  of  the  day,  and  if 
present  at  all,  only  for  one  or  two  hours.  The  patient  gained  much  in 
strength,  and  the  cough  lessened  very  materially.  Streptococci  were 
still  present  in  the  sputum,  but  the  tubercle  bacilli  were  very  scanty. 

In  the  latter  part  of  May  the  patient  returned  to  her  home,  and 
vaccine  medication  after  a  short  time  was  discontinued.     (See  Fig.  70.) 

Case  22. — A  woman,  forty-four  years  old,  was  sent  to  Colorado 
December  16,  1906,  for  supposed  tuberculosis  of  the  kidney,  her  illness 
being  of  five  years'  duration.  The  first  manifestation  of  her  present 
trouble  consisted  of  severe  uremic  symptoms  during  pregnancy,  neces- 
sitating the  induction  of  premature  labor.  One  year  later,  the  albumi- 
nuria having  persisted,  another  abortion  was  produced  for  the  same 
reason.  A  few  months  after  the  second  miscarriage  one  kidney  was 
opened  and  drained.  Since  then  she  has  had  several  uremic  attacks. 
The  following  extract  is  quoted  from  a  letter  received  from  her  attending 
physician  at  the  time  she  came  to  Colorado.  "  Four  years  ago  she 
suffered  from  frequent  and  painfid  urination,  with  the  passage  of  large 
quantities  of  pus  and  blood.  When  I  first  saw  her  she  was  confined  to 
bed  very  much  reduced,  emaciated,  with  irregidar  septic  type  of  tempera- 
ture, sweats,  etc.  We  looked  upon  the  case  as  one  of  tuberculous  kidney. 
At  the  operation  the  kidney  was  found  to  be  tuberciUous,  extensively 
disorganized  by  the  prolonged  suppurative  process,  and  densely  adherent 
to  the  adjacent  structures.  There  was  still  a  fair  amount  of  normal 
kidney  substance  left.  Her  condition  was  so  desperate  that  we  agreed 
to  incise  the  kidney  and  drain,  believing  that  removal  of  the  organ  would 
be  entirely  too  serious  an  operation  for  the  patient  in  her  condition  at 
that  time.  The  organ  was  opened  from  pole  to  pole  down  to  the  pelvis 
and  thoroughly  explored.  No  calculus  coidd  be  discovered,  but  the 
condition  was  macroscopically  one  of  tuberculosis.  Numerous  small 
caseous  nodules  were  found,  with  large  broken-down  caseating  areas. 
We  had  no  reasonable  doubt  that  the  case  was  one  of  tuberculosis. 
After  the  operation  she  slowly  improved,  and  her  health  up  to  last 
summer  was  much  better  than  we  had  anticipated.  During  the  past 
summer,  however,  she  has  again  Ijeen  losing  weight,  and  at  times  has 
had  fever.  Her  urine  contains  a  varying  amount  of  pus  and  blood. 
About  six  weeks  ago  both  were  present  in  very  large  quantities." 

At  the  time  the  patient  came  under  my  observation  there  were  pro- 
nounced pallor  and  emaciation,  with  considerable  pain  and  tenderness 
in  the  region  of  the  right  kidney.  Otherwise  the  results  of  palpation 
were  negative.  Micturition  was  very  frequent,  the  urine  being  uniformly 
dark  and  smoky  in  appearance,  acid  in  reaction,  with  specific  gravity  of 
1020.  There  was  a  large  amount  of  albumin.  The  secliment  contained 
many  pus-cells,  occasional  large  and  small  round-cells,  normal  and  abnor- 
mal blood-corpuscles.  There  was  a  pronounced  bacilluria.  Upon  ctUture 
examination  the  infecting  microorganism  was  found  to  be  the  colon  bacil- 
lus. Examination  made  three  days  later  was  attended  by  similar  results, 
save  for  the  presence  of  occasional  squamous  epithelial  cells,  a  few  cau- 
date cells,  bloody  casts,  and  an  increase  in  the  number  of  red  blood-corpus- 
cles. Exhaustive  search  failed  to  disclose  the  tubercle  bacillus,  and  in 
response  to  an  inquiry  of  her  attending  physician,  it  was  found  that  no 
bacilli  had  ever  been  discovered.  Subcutaneous  inoculation  of  guinea- 
pigs  was  subsequently  attended  by  negative  results,  although  early  peri- 
toneal inoculation  resulted  in  the  death  of  one  animal  from  colon  bacil- 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL    VACCINES      753 

lus  infection,  pure  culture  being  recovered  from  the  peritoneal  exudate. 
The  patient  was  found  to  secrete  a  normal  amount  of  urine  as  well  as 
urea.  The  urine  was  taken  from  each  kidney  by  means  of  the  Harris 
segregator,  and  the  right  kidney  was  found  to  secrete  only  one-fifth  of 
the  amount  obtained  from  the  left.  Albumin  was  found  in  each 
instance,  though  it  was  less  in  the  urine  obtained  from  the  left  kidney 
than  from  the  right.  The  same  was  true  of  the  blood-cells.  The  mi.xed 
infection  was  present  upon  both  sides,  though  but  slightly  upon  the  left. 
A  cidture  of  colon  bacilli  was  subsequently  obtained  from  the  cathet- 
erized  specimen  of  bladder  urine,  and  a  vaccine  prepared,  which  was 
so  standardized  that  each  cubic  centimeter  represented  25,000,000  colon 
bacilli.  The  first  dose  of  the  vaccine,  consisting  of  one-tenth  of  a  cubic 
centimeter,  was  administered  upon  January  27th,  and  was  continued 
with  increasing  doses  at  weeldy  intervals.  The  urine  prior  to  the  first 
administration  of  the  vaccine,  was  found  to  be  extremely  dark  and 
bloody.  After  several  days  the  urine  was  perfectly  clear  and  trans- 
parent for  the  first  time  in  many  months.  During  the  ensuing  three 
months  the  urine  was  at  no  time  other  than  of  a  light  amber  color. 
There  resulted  a  progressive  diminution  in  the  amount  of  albumin 
and  other  abnormal  constituents  of  the  sediment.  The  red  blood-cells 
became  very  scanty,  as  well  as  the  hyaline  and  granular  casts,  with 
very  slight  evidence  of  bacillary  infection. 

During  the  remainder  of  the  year  the  patient  has  continued  to  take 
the  vaccine  emulsion  at  intervals  of  from  one  to  two  weeks,  and  has 
shown  a  remarkable  degree  of  improvement.  There  has  been  no  con- 
stitutional disturbance  at  any  time  during  the  course  of  the  treatment, 
save  after  an  injection  of  50,000,000  microorganisms,  at  which  time 
there  was  a  severe  chill,  with  temperature  elevation  of  one  da.y's  dura- 
tion. The  patient  has  improved  wonderfully  in  strength,  weight,  and 
general  appearance,  which  is  now  that  of  perfect  health.  There  is  no 
longer  pain  or  discomfort  in  the  region  of  the  kidney  or  evidence  of 
bladder  irritation.  A  recent  catheterization  of  the  ureters  shows  a  very 
satisfactory  change  in  the  urine.  From  the  right  kidney  the  color  of  the 
urine  is  pale  and  clear,  and  the  amoimt  even  more  than  from  the  left, 
there  being  30  c.c.  in  one-half  hour.  The  reaction  is  acid,  and  there  is 
but  a  very  slight  trace  of  albumin.  In  each  .specimen  the  macroscopic 
sediment  was  very  slight.  Upon  microscopic  examination  occasional 
leukocytes  and  uric-acid  crystals  were  found,  but  no  casts  and  no 
bacilluria. 

Case  23. — A  man,  twenty-four  years  of  age,  arrived  in  Colorado 
January  20,  1907,  four  years  after  the  development  of  pulmonary 
tuberculosis.  After  an  early  gain  of  twenty  pounds  in  Los  Angeles 
and  its  subsequent  loss  upon  returning  home,  he  became  the  patient  of 
Dr.  Brown  at  Saranac,  where  he  remained  eleven  weeks  and  gained 
twenty-two  pounds.  He  later  returned  home  and  rapidly  declined. 
Eight  months  before  arrival  in  Colorado  there  developed  a  fluctuating 
mass  in  the  region  of  the  left  sacro-iliac  synchondrosis.  This  was 
opened  shortly  after  and  has  discharged  ever  since.  There  took  place 
a  material  loss  of  weight  and  strength.  Before  leaving  home  he  had 
remained  constantly  in  bed  for  seven  months.  A  history  of  daily 
fever  was  obtained,  the  temperature  ranging  in  the  neighborhood 
of  102°  F.  There  was  a  loss  of  thirty  pounds  in  weight  and  obsti- 
nate  diarrhea.     Extensive   active   tuberculous   involvement   of   both 

48 


754  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

lungs  was  recognized,  with  moderate  cavity  formation  in  the  left  front 
below  the  clavicle.  There  was  a  continuous  purulent  discharge  from 
the  sinus.  The  culture  was  found  to  consist  of  staphylococcus  aureus 
and  albus.  A  bacterial  vaccine  was  made  of  the  two  microorgan- 
isms, each  cubic  centimeter  of  the  vaccine  representing  100,000,000 
of  the  combined  microorganisms.  One-tenth  of  a  cubic  centimeter 
was  administered  upon  February  5th,  and  was  repeated  every  week 
in  increasing  doses  until  a  fidl  cubic  centimeter  was  given.  Previous 
to  the  beginnnig  of  the  treatment  the  patient  had  complained  of  con- 
stant deep-seated  pain  in  the  lumbar  region.  The  pus  was  thin  and 
whitish  in  appearance.  After  the  administration  of  the  vaccine  the 
pus  exhibited  a  pronounced  change  in  its  gross  appearance,  becoming 
almost  at  once  of  a  peculiar  greenish  color  and  thick  consistency.  There 
has  been  much  less  complaint  of  pain  in  the  back,  and  the  discharge 
has  continued  fairly  profuse.  Following  the  first  few  injections  there 
was  a  sharp  elevation  of  temperature  for  several  days,  anil  veiy  pro- 
nounced physical  prostration.  At  one  time  the  pulse  became  extremely 
rapid,  and  a  fatal  termination  was  feared.  There  later  developed  a 
tolerance  for  the  injections  until  there  were  no  unpleasant  symptoms 
following  their  use.  The  temperature  has  remained  at  normal  or  prac- 
tically so.  With  the  disappearance  of  fever  the  bacilli  emulsion  was 
administered.  There  ensued  a  considerable  gain  in  strength  and  a 
beginning  improvement  in  weight.  Appetite  was  much  better,  and  the 
troublesome  diarrhea  was  controlled.  There  took  place,  however,  no 
special  variation  in  the  staphylococcic  index,  though  the  tuberculo- 
opsonic  index  when  last  recorded  was  1.6. 

After  exhibiting  satisfactory  improvement  as  above  noted,  despite 
an  extremely  desperate  condition,  the  patient  suffered  a  sudden  change 
for  the  worse  after  several  months'  vaccine  treatment,  and  died  in  the 
late  spring  of  1907.  An  appreciation  of  the  advanced  condition  may  be 
afforded  by  reference  to  Figs.  52,  115,  and  116. 

Case  24. — A  woman,  forty-two  years  old.  consulted  me  in  June,  1906, 
four  years  after  the  development  of  pulmonary  tuberculosis,  exhibiting 
a  loss  of  twenty  pounds  in  weight,  an  exceedingly  rapid  pulse,  and 
dyspnea  without  fever.  There  was  extensive  active  tuberculous  infec- 
tion of  each  lung,  moist  rales  being  recognized  upon  the  left  side  from 
the  apex  to  the  fourth  rib.  There  was  a  large  cavity  lielow  the  clavicle. 
Upon  the  right  side  moisture  was  present  from  the  apex  to  the  third  rib, 
and  in  each  back  from  the  apex  nearly  to  the  base.  Cough  was  especially 
severe,  the  expectoration  copious,  and  bacilli  were  numerous.  An  acute 
appendicitis  shortly  de\-eloped,  for  which  an  early  operation  was  per- 
formed. There  resulteil  a  persisting  sinus  and  a  free  purulent  discharge, 
incident  to  a  tuberculous  and  staphylococcic  infection.  A  vaccine  was 
made  from  the  staphylococcus  albus  culture,  and  administered  weekly 
with  injections  of  new  tuberculin.  The  beginning  tuberculo-opsonic 
index  was  0.45,  and  the  staphylococcic,  0.65.  Upon  the  day  following 
the  first  tuberculin  injection,  .January  17th,  there  was  marked  redness  of 
the  edges  of  the  sinus,  and  a  greatly  increased  discharge,  which  cea.sed 
entirely  upon  the  third  day.  The  opening  of  the  sinus  remained  closed 
until  the  succeeding  injection,  which  was  followed  by  a  repetition  of  the 
previous  increased  discharge  and  its  subsidence  upon  the  third  day. 
No  appreciable  symptoms  followed  immediately  the  injections  of  the 
staphylococcic  vaccine.     After  three  injections  of  each  agent  the  sinus, 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL    VACCINES       755 

which  had  persisted  during  a  period  of  six  months,  became  permanently 
closed.  Progressive  improvement  has  taken  place  in  the  general  con- 
dition, the  cough  and  expectoration  becoming  much  diminished. 

The  gain  during  the  remainder  of  1907  has  been  quite  remarkable 
as  the  probable  result  of  weekly  injections  of  tuberculin.  The  patient 
has  gained  twenty-five  pounds  in  weight  and  correspondingly  in 
strength.  There  is  a  pronounced  lessening  in  the  activity  of  the 
tuberculous  process,  as  shown  by  the  physical  signs  and  the  exceed- 
ingly few  tubercle  bacilli. 

Case  25. — This  case  is  of  especial  interest  by  virtue  of  the  detection 
of  an  enlarged  mediastinal  gland  adjacent  to  the  sixth  dor.sal  vertebra 
upon  the  left  side.  The  early  history  of  this  patient,  the  peculiar 
subjective  symptoms,  and  characteristic  physical  signs  resulting  from 
bronchial  occlusion,  together  with  the  laryngoscopic  appearance,  have 
been  described  under  the  subject  of  Glandular  Tuberculosis.  A  photo- 
graph showing  the  area  of  percussion  dulness  and  a  skiagraph  of  the 
chest  have  also  been  exhibited.  It  only  remains,  therefore,  to  detail 
briefly  the  subsequent  history. 

The  sputum  was  found  to  contain  innumerable  tubercle  bacilli  and 
staphylococci.  A  staphylococcic  vaccine  was  prepared  of  such  a 
strength  that  each  cubic  centimeter  lejiresented  60,000,000  microorgan- 
isms. The  patient  receivod  four  injciiinns  of  the  vaccine  and  three  of 
the  new  tuberculin.  An  fHoii  \\;i.s  made  tn  ,t;ive  the  tuberculin  every 
two  weeks,  but  this  was  not  adlicied  to  strirtly  on  account  of  the  varia- 
bility of  temperature,  the  bacilli  emulsion  not  being  administered 
during  the  time  of  high  fever.  Following  each  dose  of  the  vaccine,  the 
temperature  rose  several  degrees  and  remained  very  high  for  two  or 
three  days,  but  the  tuberculin  at  no  time  produced  increased  fever. 
One  week  following  the  first  dose  of  tul)erculin  a  decided  improvement 
was  noted  in  the  amount  of  air  passing  through  the  left  bronchus,  and 
the  respiratory  sounds  were  distinctly  heard  throitghout  the  left  lung 
for  the  first  time.  This  was  also  recognized  by  Dr.  ,J.  N.  Hall,  by  whom 
the  patient  was  examined  as  a  matter  of  interest  before  the  first  injection 
and  at  the  expiration  of  one  week.  The  improvement  in  the  respiration 
upon  the  left  .side  continued  marked,  especially  at  the  end  of  six  or 
seven  days  after  each  injection.  It  was  noted,  however,  that  less  air 
pas.sed  through  the  bronchial  tube  during  the  first  few  days  after  the 
remedy  was  given.  There  was  exhibited  a  gain  in  the  general  strength, 
a  diminished  dyspnea,  and  a  somewhat  lessened  temperature  elevation. 
The  cough  and  exficctdiatinn.  howo\-('r,  wcw  ]H'rcpptibly  inneased. 
No  appreciable  chaimc  wa-  noicd  in  the  uuinlicr  of  bacilli.  At  the  end 
of  six  weeks  the  fiuliier  ohscr\ation  of  the  case  was  terminated  by  a 
sudden  fatal  hemorrhage.     (See  Fig.  55.) 

Case  26. — A  woman  of  twenty-four  j^ears  came  under  my  observa- 
tion January  12,  1907,  immediately  upon  arrival  in  Colorado,  four 
months  after  the  development  of  a  rapidly  progressing  pulmonary 
tuberculo.sis.  There  was  a  loss  of  thirty-three  pounds  in  weight, 
together  with  marked  prostration.  A  fever  of  104°  F.  daily  was  ex- 
hibited, with  a  correspondingly  weak  and  rapid  pulse.  Night-sweats 
were  severe,  cough  distressing,  expectoration  four  ounces  in  twenty- 
four  hours.  The  right  lung  was  found  diseased  from  apex  to  base. 
Throughout  this  region  there  was  moderate  consolidation,  with  numer- 
ovis  coarse  and  medium-sized  bubbling  rales,  while  upon  the  left  side 


756  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

moisture  was  detected  from  the  apex  to  the  third  rib  and  to  the  lower 
angle  of  the  scapula.  Bacilli  were  exceedingly  numerous.  The  mixed 
infection  was  found  to  be  pneumococcic  in  character.  During  a  period 
of  three  weeks  the  patient  was  kept  constantly  in  bed  in  the  open  air, 
without  the  slightest  evidence  of  resulting  improvement.  In  fact,  there 
was  noted  a  further  decline  in  strength  and  weight,  while  the  fever  per- 
sisted daily  between  103°  and  104°  F.  On  February  5th  the  first  dose 
of  pneumococcic  vaccine  was  administered,  consisting  of  nearly  5,000,000 
microorganisms.  This  has  been  repeated  in  increasing  doses  during 
a  period  of  three  months.  No  decided  impro\ement  was  observed 
during  the  first  six  weeks,  although  a  temporary  reduction  of  fever  was 
noted  in  some  instances  two  or  three  days  after  the  vaccine  was  admin- 
istered. Immediately  after  the  injections,  there  was  often  experienced 
a  feeling  of  lassitude  and  general  malaise,  with  occasional  elevations  of 
temperature.  The  fever  remained,  upon  the  whole,  discouragiugly 
high,  appetite  and  digestion  poor,  with  continued  loss  of  flesh  and 
strength.  During  the  second  six  weeks  there  was  observed  a  pronounced 
diminution  of  temperature,  with  increase  of  strength,  revival  of  spirits, 
and  gain  in  weight.  The  cough  and  expectoration  became  considerably 
less,  and  the  appetite  revived.  The  temperature  rarely  exceeded  100° 
F.,  and  the  patient  was  able  to  be  out  of  bed  in  the  open  air.  Thus  far 
no  tuberculin  has  been  administered,  as  it  has  not  been  deemed  wise  to 
risk  disturbing  the  existing  improvement.  For  some  reason  the  tubercle 
bacilli  have  become  much  less  numerous. 

During  the  ensuing  six  months  the  patient  has  continued  to  exhibit 
a  gratifying  gain  in  all  respects,  without  the  slightest  tendency  toward 
retrogression. 

Case  27. — An  interesting  feature  in  connection  with  the  preceding 
case  is  the  fact  that,  in  the  early  summer  of  1907.  a  sister  of  the  patient, 
fourteen  years  of  age,  was  brought  to  Colorado  in  an  almost  precisely 
identical  condition.  The  illness  had  been  of  one  year's  duration,  and 
was  attended  by  an  acute  onset  following  influenza.  The  child  had 
exhibited  high  ele\"ations  of  temperature  daily.  These  were  preceded, 
however,  by  moderately  sharp  rigors.  The  pidse  ranged  from  124  to 
140,  and  was  uniformly  of  poor  quality.  Cough  was  frequent,  and 
expectoration  profuse.  The  clinical  picture  was  that  of  pronounced 
sepsis.  Examination  of  the  chest  disclosed  pronounced  consolidation 
of  the  right  lung  from  apex  to  base,  with  coarse  bubbling  rales  through- 
out this  region;  on  the  left  side,  fine  moist  rales  after  cough  from  apex 
to  ba.se.  Tubercle  bacilli  were  numerous,  and  a  pneumococcic  culture 
was  obtained  from  the  sputum.  Upon  the  score  of  the  expense  incident 
to  the  preparation  of  an  autogenetic  vaccine,  and  in  view  of  the  similarity 
of  the  infection,  it  was  determined  to  employ  the  same  remedy  which  iiad 
previously  been  administei'ed  to  the  sister.  This  was  given  at  weekly 
intervals  during  a  period  of  four  months.  No  improvement  was  noted 
after  the  first  five  or  six  injections.  Upon  the  contrary,  the  fever  was 
invariably  higher  immediately  following  its  administration.  With  a 
gradual  recession  of  the  fever,  however,  there  took  place  a  very  pro- 
nounced improvement  in  the  general  condition. 

During  the  last  three  or  four  months  of  1907  there  has  been  at  no 
time  any  elevation  of  temperature.  The  child  has  gained  eighteen 
pounds  in  weight,  with  a  corresponding  lessening  in  the  activity  of  the 


PERSONAL  OBSERVATIONS  UPON  USE  OF  BACTERIAL  VACCINES   757 

tuberciilous  process,  as  shown  by  the  physical  signs,  with  lessening  of 
cough  and  expectoration. 

Case  28. — A  man  of  forty-eight  years  was  brought  to  Colorado 
January  5,  1907.  The  tuberculous  infection  had  been  of  six  months' 
duration,  during  which  time  the  progres.s  of  the  disease  had  been  quite 
rapid.  A  loss  of  forty-eight  pounds  had  taken  place,  and  the  condition 
was  one  of  utter  prostration.  There  were  frequent  chills  and  daily 
elevations  of  temperature  of  104°  F.,  followed  by  drenching  sweats. 
The  mental  condition  was  that  of  marked  stupor,  the  patient  failing  to 
comprehend  thoroughly  the  nature  of  direct  questions.  His  speech 
was  slow  and  hesitating,  and  the  answers  incoherent.  I  learned  from 
his  brother  that  this  condition  had  been  of  several  weeks'  duration. 
The  face  was  uniformly  cyanotic,  the  pulse  averaging  from  136  to  144. 
Loud  bubbling  rales  were  heard  upon  easy  respiration  throughout  both 
lungs.  Bacilli  were  numerous,  as  were  also  the  pneumococcus  and 
staphylococcus  aureus  and  albus.  The  patient  was  given  the  pneumo- 
coccic  vaccine  on  February  5th.  Three  doses  were  administered  at 
intervals  of  one  week,  and  were  followed  after  a  few  hours  in  each 
instance  by  a  shar])  lii^di'.  increased  fever,  and  extreme  prostration.  It 
wasfeared  afterthc  tlmd  injection  that  the  patient  would  not  be  able  to 
survive  in  spite  of  (■\cc>>i\ c  stimulation  and  subcutaneous  salt  infusions. 
He  eventually  rullicil,  ;ind  was  later  given  the  first  injection  of  staphylo- 
coccic vaciinc:  I'ucli  cubic  centimeter  consisted  of  100,000,000  micro- 
organisms, the  iuitiul  (lose  being  one-tenth  of  a  cubic  centimeter.  There 
was  no  chill  or  other  evidence  of  general  disturbance  follDwiiii;  iliis  injec- 
tion, although  the  temperatui'e  remained  high  for  two  il:iy<.  \']um  the 
third  day  the  fever  suddenly  subsideil.  the  temperature  rcinaiuinu-  in  the 
vicinity  of  normal  for  over  a  week.  Tliis  was  accompanied  by  a  remark- 
able improvement  in  the  mental  ((UKlii  imi.  the  patient  becoming  entirely 
rational,  the  cyanotic  flush  dis;t])|ie:ii  iiiu  liom  the  face,  and  the  pulse 
declining  to  the  eighties.  The  st:i,]ili\  locdciic  vaccine  was  subsequently 
administered  every  ten  days,  tniivilier  with  occasional  injections  of 
a  vaccine  prepared  from  the  staiili^lncoccus  albus.  At  no  time  there- 
after did  the  copious  daily  sweats  recur,  nor  did  the  mental  condition 
again  become  clouded.  There  were  occasional  exacerbations  of  tem- 
perature of  a  few  days'  duration,  but  these  were  comparatively  infre- 
quent and  never  attained  a  high  degree.  The  cciimh  and  expectoration 
were  considerably  lessened.  It  was  apparent,  lidwexcr.  that  I  lie  tuljer- 
culous  infection  was  too  far  advanced  to  warrant  any  reusi)ii:il>le  hope 
of  a  sustained  improvement,  and  the  patient  finally  succumbed  to 
general  exhaustion. 

Case  29. — A  woman  of  forty-three,  after  a  three  years'  illness,  came  to 
Colorado  June  13,  1905,  coming  under  my  observation  six  months  later 
with  extensive  tuberculous  infection  of  both  lungs,  the  left  side  being 
actively  diseased  throughout.  There  were  daily  fever  of  two  or  three 
degrees,  occasional  chills  and  night-sweats,  much  exhaustion,  and  the 
history  of  a  progressive  decline.  She  remained  in  the  recumbent  position 
in  the  open  air  for  nearly  one  year  without  showing  any  satisfactory 
evidence  of  beginning  improvement.  In  January,  1907,  there  had  been 
a  further  decided  loss  of  weight  and  strength,  the  temperature  remaining 
between  102°  and  103°  F.  daily,  while  the  cough  and  expectoration  were 
pronounced.  The  sputum  was  found  to  contain  not  only  very  many 
bacilli,  but  also  numerous  streptococci.     A  streptococcic  vaccine  was 


758  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

administered  Felnuary  4th  and  was  repeated  weekly  without  pronounced 
effects  immediately  referable  to  the  injections,  although  in  one  or  two 
instances  there  resulted  moderate  temperature  elevation  for  one  or  two 
days.  There  developed,  however,  in  the  cour.^e  of  three  months  a  con- 
siderable increase  of  strength  and  a  gradual  dhninution  of  fever,  with 
lessening  of  cough.  The  temperature  remained  in  the  neighborhood  of 
100°  F.  and  rarely  reached  101°  F. 

The  improvement  in  the  general  condition  thus  noted  was  followed 
in  the  late  summer  by  frequent  exacerbations  of  fever,  attended  by 
marked  prostration.  Under  these  conditions  the  vaccine  was  chscon- 
tinued.     The  patient  rapidly  declined,  and  died  in  the  latter  part  of  1907. 

Case  30. — A  man,  forty-one  \-ears  old,  who  had  previously  secured 
a  complete  arrest  of  pulmonary  tuberculosis  in  Colorado  and  was  in 
active  business,  experienced,  early  in  February,  1907,  a  severe  rigor  and 
speetlily  developed  a  typical  croupous  pneumonia.  The  expectoration 
was  bloody,  respiration  short,  jerky,  and  painful,  and  the  cough  most  dis- 
tressing. It  was  early  apparent  that  the  condition  was  to  be  an  exceed- 
ingly desperate  one.  Upon  the  fourth  da}'  it  was  decided  to  prepare  a 
pneumococcic  vaccine  from  the  Woody  expectoration,  although  it  was 
hardly  thought  likely  that  the  patient  would  survive  until  the  vaccine 
could  be  in  readiness  for  administration.  By  the  time  this  was  prepared 
upon  the  eighth  day,  the  crisis  had  apparently  passed,  and  the  general 
outlook  was  quite  reassuring,  suggesting  the  inexpediency  of  vaccine 
therapj-  in  this  case.  The  patient  rapidly  improved  for  fom-  or  five  days, 
when  there  developed  unexpectedly  another  severe  rigor,  and  the  tem- 
perature rose  to  10.5°  F.,  with  recurrence  of  bloody  expectoration,  diffi- 
cult and  rapid  respiration,  and  great  prostration.  Examination  of 
chest  disclosed  an  extension  of  the  pneumonic  process  to  the  other 
lung,  as  shown  by  the  recognition  of  the  crepitant  rale  and  beginning  con- 
solidation. The  vaccine  was  immediately  administered.  Eight  hours 
later  the  temperature  was  normal  and  remained  so  for  about  fourteen 
hours,  when  it  again  rose  sharply,  preceded  by  a  distinct  chilling. 
Upon  the  succeeding  dav-  the  temperature  remained  constantly  elevated, 
although  the  general  condition  was  improved.  A  noteworthy  feature 
at  this  period  was  the  failure  of  the  second  lung  to  proceed  to  gross 
consolidation,  as  in  the  former  instance.  The  temperature  still  remain- 
ing elevated  upon  the  third  day  after  the  injection,  another  dose  of  the 
vaccine  was  administered.  This,  like  the  preceding,  was  followed 
by  a  speedy  and  pronounced  decline  of  the  fever,  which  subsequently 
recurred,  however,  upon  the  following  day.  The  vaccine  was  repeated 
eveiy  third  or  fourth  day.  Several  examinations  of  the  sputum  failed 
to  disclose  the  presence  of  tubercle  bacilli.  After  several  weeks  of  con- 
valescence the  patient  proceeded  to  complete  recovery. 

Case  31. — A  man  of  fifty-five  years  came  under  observation  March 
18,  1907,  six  years  after  arrival  in  Colorado.  The  tuberculous  infection 
developed  twenty  vears  before.  Cough  and  expectoration  had  been 
particularly  severe  during  this  entire  period.  Nutrition,  however, 
had  been  preserved  to  a  remarkable  extent.  He  had  traveled  exten- 
sively, visiting  numerous  health  resorts  in  this  country  and  abroad, 
and  had  been  subjected  for  prolonged  periods  to  a  considerable  variety 
of  special  treatments.  Several  years  ago  a  large  cavity  was  diagnosed 
in  the  upper  portion  of  the  right  lung,  and  the  second  and  third  ribs 
were  excised  in  the  hope  of  producing  a  retraction  of  the  chest-wall  and 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL    VACCINI 


759 


thus  securing  a  partial  obliteration  of  the  cavity.  The  site  of  the 
incision  is  shown  in  the  accompanying  illustration  (Fig.  169).  Upon 
coming  under  my  observation,  the  examination  of  the  chest  showed 
an  area  of  consolidation  in  the  upper  portion  of  the  right  lung,  with 
numerous  fine  and  medium-sized  moist  rales  from  the  apex  to  the 
fourth  rib,  with  a  suspicion  of  cavity  below  the  clavicle.  No  tubercle 
baciUi  were  found  in  the  sputum.  The  skiagraph  disclosed  an  entire 
absence  of  cavity  formation,  but  a  sharply  localized  consolidation  in  the 
upper  portion  of  the  lung.  Upon  bacteriologic  examination  numerous 
colonies  of  micrococcus  catarrhalis  were  found.  A  vaccine  was  pre- 
pared, and  the  remedy  ailministered  upon  April  1st.  The  first  dose 
consisted  of  50,000,000  microorganisms.  This  has  been  increased  until 
the  patient  received  15(J,000,000  at  each  injection.     After  six  or  eight 


injections  a  beginning  improvement  was  noted  in  the  amount  of  cough 
and  expectoration. 

The  efficacy  of  the  vaccine  in  this  case  is  quite  apparent  from  the 
fact  that  during  the  remainder  of  li»()7  tlie  i)atient  has  coughed  but 
little,  and  has  shown  an  iniprcn-ement  in  the  physical  signs  with  dis- 
appearance of  the  microorganisms  in  the  sputum. 

Case  32. — ^'ery  pronounced  improvement  has  attended  the  adminis- 
tration of  a  staphylococcic  vaccine  in  a  case  of  an  apparently  hopeless 
consumptive  with  tuberculous  laryngitis.  The  patient  was  a  young 
woman,  twenty-four  years  of  age,  who  came  to  Colorado  March,  1907, 
one  year  after  the  development  of  her  pulmonary  involvement.  For 
six  weeks  before  arrival  severe  rigors  were  experienced  daily,  followed 
by  sharp  elevations  of  temperature.  There  were  pronounced  emacia- 
tion and  prostration.  Examination  of  the  chest  disclosed  active 
tuberculous  involvement  in  the  left  lung  from  apex  to  base,  front  and 


760  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

back,  with  coarse  bubbling  rales  throughout  this  region;  on  the  right 
side,  from  the  apex  to  the  third  rib  and  to  the  lower  angle  of  the  scapula. 
There  was  a  large  cavity  in  the  right  front  under  the  clavicle.  The 
condition  was  so  desperate,  it  did  not  seem  that  the  slightest  encourage- 
ment could  be  offered.  The  staphylococcic  vaccine  was  prepared 
and  administered  at  weekly  intervals.  This  was  commenced  in  the 
middle  of  March,  and  after  a  few  weeks  produced  a  perceptible  diminu- 
tion in  the  maximum  daily  temperature.  Following  the  first  three  or 
four  injections  the  fever  was  increased,  and  the  general  prostration  more 
marked.  The  patient,  however,  invaiiably  volunteered  the  information 
four  or  five  days  after  its  administration  that  she  felt  better  than  before 
it  was  given. 

In  the  latter  part  of  August  the  temperature  returned  to  normal, 
and  has  remained  so  until  January  1,  1908.  The  patient  has  gained 
twenty  pounds  in  weight,  and  examination  of  the  chest  shows  but 
very  slight  moisture  in  the  lungs.  Cough  and  expectoration  are  much 
diminished. 

Case  33. — A  man  of  thirty-nine  consulted  me  June  6,  1907,  imme- 
diately upon  arrival  in  Colorado,  presenting  the  history  of  pulmonary 
tuberculosis  of  over  one  }-ear's  duration.  The  onset  was  acute,  and 
the  decline  progressive.  There  were  marked  loss  of  weight,  copious 
purulent  expectoration,  and  dyspnea  upon  the  slightest  exertion.  The 
temperature  was  elevated  daily  to  the  neighborhood  of  from  103°  to 
104°  F.,  with  marked  acceleration  of  pul.se.  The  examination  of  the 
chest  disclosed  the  presence  of  active  and  extensive  tuberculous  infec- 
tion, the  area  involved  upon  the  right  side  extending  from  the  apex  to 
the  base,  with  moderate  consolidation  throughout  and  a  small  cavity 
below  the  clavicle.  Upon  the  left  side  the  process  was  less  active, 
though  fine  clicks  were  heard  over  the  entire  lung.  During  a  period  of 
two  months  the  patient  was  kept  in  bed  upon  a  large  protected  porch, 
a  rigid  enforcement  of  hygienic  and  dietetic  principles  being  secured 
by  the  attendance  of  a  nurse.  Despite  these  important  features  of 
regimen,  no  abatement  of  temperature  or  other  e\idence  of  improvement 
was  noted.  A  bacteriologic  examination  disclosed  a  pronounced 
streptococcic  infection,  and  upon  July  28th  the  bacterial  vaccine  was 
administered  for  the  first  time,  the  maximum  temperature  for  that 
day  being  registered  as  103°  F.  Upon  the  second  day  the  temperature 
rose  to  103.6°  F.,  and  on  the  third  day  was  103°  F.  In  the  course  of 
three  weeks  the  temperature  gradually  subsided  to  normal  or  there- 
abouts. During  the  ensuing  five  months  the  temperature  has  rarely 
exceeded  100°  F.,  and  has  averaged  in  the  vicinity  of  99i°  F.  in  the 
afternoon,  the  vaccine  being  administered  at  intervals  of  one  week. 
The  fall  of  temperature  has  been  attended  by  corresponding  evidences 
of  constitutional  improvement. 

During  the  eight  months  that  have  elapsed  since  the  writing  of 
the  foregoing  pages  extended  opportunities  have  been  offered  for  closer 
observation  of  the  effects  of  the  bacilli  emulsion  and  of  the  homologous 
vaccines.  These  agents  have  been  employed  in  a  considerable  number 
of  cases  since  the  preparation  of  the  previous  report.  In  using  the 
bacilli  emulsion,  the  same  principles  have  been  applied  in  the  selection 
of  cases  as  in  the  first  group,  the  administration,  as  a  rule,  being  restricted 
to  individuals  who  had  remained  for  prolonged  periods  in  Colorado 
without  achieving  entirely  satisfactory  results.     No  permanent  dis- 


PERSONAL    OBSERVATIONS    UPON    USE    OF    BACTERIAL   VACCINES       761 

agreeable  effects  have  thus  far  been  observed  from  its  employment 
among  an  increasing  number  of  patients,  and  a  general  upward  tendency 
has  been  exhibited  in  many  instances.  The  i-emedy  was  invariably 
denied  to  incipient  cases.  The  skiagraph  (Fig.  67)  illustrates  the 
extensive  pathologic  changes  in  an  individual  exhibiting  frequent 
cough  and  copious  expectoration,  with  a  resulting  entire  disappearance 
of  tubercle  bacilli.  The  tubercuhn  has  been  thought  to  be  of  value 
in  several  cases  of  tuberculous  laryngitis.  Improvement  has  also 
followed  its  application  in  a  few  additional  cases  of  glandular  tubercu- 
losis. In  my  own  practice,  with  one  exception,  neither  the  bacilli 
emulsion  nor  the  autogenetic  vaccines  have  been  given  more  frequently 
than  once  in  five  days.  Neither  have  I  found  it  advisable  in  many  cases 
to  resort  to  progressive  increase  of  dosage.  This,  perhaps,  explains 
the  absence  of  intolerance  in  my  later  experience,  as  contrasted  with 
previous  occasional  manifestations  of  local  reaction  with  headache, 
fever,  malaise,  and  loss  of  appetite  for  a  few  days  following  the  injections. 
In  but  few  instances  has  the  agent  been  used  for  patients  presenting  a 
temperature  of  over  100°  F.  It  is  interesting  to  note,  however,  that 
Krause  has  recently  reported  excellent  results  from  the  administration 
of  tuberculin  to  febrile  patients.  He  reports  a  permanent  disappear- 
ance of  the  fever  in  all  cases,  and  suggests,  at  least,  a  tentative  adminis- 
tration of  the  remedy  among  a  few  patients  who  have  resisted  all  other 
measures. 

Recently  I  have  had  occasion  to  employ  the  tuberculin  in  6  cases 
exhibiting  persisting  fever  of  from  102°  to  10.3°  F.  daily,  despite  pro- 
longed rest  in  bed  in  the  open  air.  In  3  cases  no  appreciable  effects 
were  noted;  in  one  the  temperature  receded  within  a  few  days  to  normal 
and  has  remained  so  for  four  weeks;  in  2  cases  the  temperature  has 
gradually  receded  to  the  neighborhood  of  99°  and  99.5°  F. 

Special  bacterial  vaccines  have  been  prepared  for  twelve  recent 
cases  of  severe  mixed  infection,  making  a  total  of  twenty-seven  patients 
to  whom  the  homologous  vaccines  have  been  administered. 

In  the  use  of  both  the  tuberculin  and  the  bacterial  vaccines  among 
eases  observed  during  the  past  few  months,  the  dosage  has  been  deter- 
mined without  reference  to  the  opsonic  index.  This  course  has  been 
pursued  because  determinations  of  the  index  sufficiently  frequent  to 
afford  a  basis  for  substantial  accuracy  of  dosage  were  almost  impracti- 
cable. It  was  found  that  even  in  carefully  selected  cases  of  pulmonary 
tuberculosis,  the  range  of  variation  in  the  opsonic  findings  was  so  great 
as  to  suggest  the  impropriety  of  any  arbitrary  or  conventional  dosage 
without  recourse  to  detailed  clinical  study.  There  was  found  to  be  no 
fixed  relation  between  the  opsonic  variations  and  the  character  of  the 
clinical  manifestations.  In  view  of  the  unavoidable  sources  for  error 
in  estimating  the  index,  and  the  confusing  interpretations  as  to  the 
dosage,  it  was  decided  to  permit  the  character  of  clinical  manifestations 
to  be  the  sole  guide  for  tentative  medication.  The  results  obtained 
have  demonstrated  fully  that,  for  practical  purposes,  approximate 
accuracy  of  judgment  in  this  respect  may  be  derived  from  a  continuous 
vigilant  study  of  the  subjective  and  physical  data.  In  the  light  of 
later  experience  it  is  questionable  if,  for  general  usage,  the  clinical 
method  of  dosage,  influenced  solely  by  the  symptomatic  course,  is  to  be 
displaced  by  the  laboratonj  method,  controlled  by  the  observation  of 
the   opsonic   index.     The   same   conclusions    have   been   reached    by 


762  PROPHYLAXIS,    GENERAL    AND    SPECIFIC    TREATMENT 

Trudeau,  Baldwin,  Brown,  and  other  clinicians  in  various  parts  of  the 
country. 

It  is  recognized  that,  amid  the  many  complicating  conditions 
inherent  to  the  disease  and  its  management,  many  difficulties  obtain  in 
establishing  the  value  of  any  therapeutic  agent.  It  is  fair  to  assume, 
however,  from  the  accumulating  mass  of  evidence,  that  the  use  of 
tuberculin  and  bacterial  vaccines  is  in  accord  with  modern  theories 
relative  to  the  production  of  artificial  immunity. 

As  a  result  of  my  investigations,  which  were  pursued  largely  along 
clinical  lines,  the  following  conclusions  are  suggested: 

1.  In  general  it  may  be  stated  that  the  administration  of  bacilli 
emulsion  is  of  undoubted  efficacy  in  so7ne  cases  of  long-standing  afebrile 
pulmonary  tuberculosis. 

2.  That  the  remedy  also  possesses  possibilities  of  an  injurious  influ- 
ence. 

3.  That  the  demonstration  of  an  increase  in  cough  and  expectoration 
shortly  after  the  injection  is  not  necessarily  indicative  of  its  harmful 
effect. 

4.  That  the  persistence  of  these  clinical  manifestations,  together 
with  fever  and  greater  physical  weakness,  despite  an  attempted  dis- 
crimination regarding  the  dosage,  may  be  accepted  as  definitel}'  con- 
clusive of  its  detrimental  action. 

5.  That,  in  the  event  of  severe  mixed  infection  with  considerable 
temperature  elevation,  it  is  highly  inexpedient,  as  a  rule,  to  attempt 
the  production  of  an  increased  tuberculo-opsonic  power  until  after  the 
amelioration  of  the  secondary  infection. 

6.  That  the  administration  of  bacterial  vaccines  derived  from  the 
secretions  of  the  patient  is  often  indicated  in  the  presence  of  the  consti- 
tutional and  bacteriologic  evidences  of  mixed  infection. 

7.  That,  in  view  of  the  numerous  possiljilities  of  error  incident  to  the 
opsonic  findings,  discriminating  clinical  shidy  is  absolutely  essential  in 
the  determination  of  the  size  and  frequency  of  the  dosage. 

8.  That  despite  the  uncertainties  of  action  of  autogenetic  vaccines, 
a  justification  for  their  employment  is  found  in  the  desperate  character 
of  the  cases  to  which  they  are  given,  and  their  superiority  over  the 
various  sera  formei'ly  used. 

9.  That  in  some  cases  bacterial  vaccines  present  possibilities  of 
benefit  far  bej'ond  the  limits  of  former  therapeutic  efforts. 

10.  That  the  role  of  the  opsonic  index  in  vaccine  therapy  still  remains 
an  experimental  study,  to  be  approached  with  the  utmost  conservatism, 
but  in  a  spirit  of  receptive  inquiry.  The  data  thus  far  presented  suggest 
that  this  feature  should  remain  for  the  present  sub  judice. 


INDEX 


5,  tuberculous,  in  bone  and  joint 
tuberculosis,  treatment,  461 
Acceleration  of  pulse,  120 

diagnostic  import,  2-13 
Adenoid  vegetations  as  port  of  entrance 

for  tubercle  bacillus,  415 
Adherent  pericardium,  403 
Broadbent's  sign  in,  404 
Friedreich's  sign  in,  404 
Administrative  control,  601 
Advanced  cases,  physical  signs.  229 
Age,  influence,  on  prognosis,  301 
Air,  existence  in,  comfort  and  shelter  in, 
629 
enforcement  of,  629 
walking  in,  in  treatment,  621 
Air-hunger,  107 
Alcohol  in  tuberculosis,  646 
Alimentary  tract,  infection  through,  51 
tuberculosis  of,  462 
anatomic  factors,  462 
etiology,  462 
Altitude,  influence  of,  on  nervous  system, 
678 
on  red  blood-corpuscles,  677 
on  respiratory  rate,  678 
on  tissue  change,  677 
variations  in  blood-pressure  at,  677 
Amphoric  resonance,  189 

respiration,     changes     in     pitch     and 

quality,  208 
voice,  216 
Anatomic  wart,  513 
Anatomy,  pathologic,  17,  76 
Anemic  onset,  100 
Animals,     experiments     on,     diagnostic 

import,  251 
Ankles,  edema,  123 

Antistreptococcic  serum  in  mixed  infec- 
tion, 547 
Apex    of    heart,     cardiac    impulse    at, 
changes  in,  172 


Apex-beat,  changes  in  location,  172 
Apical      rales,      unilateral,      diagnostic 

import.  244 
Appendicitis,  tuberculous,  471.     See  also 

Vermiform  appendix,   tuberculosis  of. 
Appendix,    vermiform,    tuberculosis   of, 

471.     See  also    Vermiform  appendix, 

tuberculosis  of. 
Area  of  cardiac  dulness,  185 

flatness,  186 
Arsenic  in  phthisis,  724 
Aspiration    in    glandular    tuberculosis, 
435 

in   serous  effusion  in   tuberculosis   of 
pleura,      indications      and 
contraindication.^,  308 
rules,  370 
Asthmatic  breathing,  204 
Atropin  in  pulmonary  hemorrhage,  719 
Auscultation,  191 

in  pathologic  conditions,  203 

manner,  192 

of  broncliial  respiration,  200 

of  che,st,  199 

of  res|5iratory  sounds,  199 

of  vesicular  respiration,  199,  200 

rules,  198 

with  stethoscope,  193 


Bacillus,  lepra,  and  tubercle  bacillus, 
resemblance,  21 
tubercle,       19.     See      also      Tubercle 
bacillus. 
Bacterial   vaccines   in   mixed   infection, 
549 
in  tuberculosis,  738 
Bacteriolysis  and  immunity,  732 
Bacteriotrophins,  733 
Bamberger's    sign     in     tuberculosis    of 

pericardium,  398 
Barrel  chest,  163 


763 


764 


Bier  treatment  of  tuberculous  joints,460 
Bladder,    cystoscopic    examination,    in 
renal  tuberculosis,  494 
tuberculosis  of,  488,  499 
curetment  in,  502 
cystotomy  in,  502 
diagnosis,  500 
primary,  499 
symptoms,  500 
treatment,  501 
Blood  in  sputum,  104,  124 
Blood-corpuscles,  red,  influence  of  alti- 
tude on,  677 
Blood-pressure,    variations    in,    at    dif- 
ferent altitudes,  677 
Blood-vessels,  palpation,  176 
Bones,  tuberculosis  of,  440 

clinical  manifestations,  444 
etiology,  440 

microscopic  pathology,  443 
prognosis,  446 
symptoms,  early,  444 
treatment,  457 
hygienic,  457 
local,  458 

non-operative  measures,  459 
surgical,  461 
tuberculous  abscess  in,  treatment, 
461 
Bovine  tuberculosis  and  human  tuber- 
culosis, relation,  27,  517 
Bowles'  stethoscope,  197 
Breast,  funnel,  165 

pigeon-,  163 
Breatliing.     See  Respiration. 
Broadbent's   sign   in   adherent   pericar- 
dium, 403 
Broncliial   compression,   physical   signs, 
in  tuberculosis  of  mediastinal  glands, 
423 
glands,  tuberculosis,  415 

treatment.  429 
irritation,  102,  639 
onset.  99 
rales,  dry.  212 

moist.  211 
respiration,  auscultation,  200 

changes  in  pitch  and  quality,  206 
Bronchitis,  acute,  comphcating  phtliisis, 
pain  in,  107 
onset,  99 
Bronchocavernous  respiration,  208 
Bronchophony,  203,  216 


Bronchopneumonia  after  pulmonary 
hemorrhage,  treatment,  719 

Bronchopneumonic  phthisis,  acute, 
method  of  onset,  95 

Bronchovesicular  respiration,  202 

changes  in  pitch  and  quality,  206 

Buccal  mucous  membrane,  tuberculous 
lesions  of,  462 

Buildings,  public,  hygienic  construction 
and  sanitary  supervision,  in  pro- 
phylaxis, 605 


Calmette     and     Wolff-Eisner's     oph- 

thalmotuberculin  reaction,  249 
Camman's  stethoscope,  194 
Canopy,  sleeping,  629 
Cardiac  dulness.  area  of,  185 

flatness,  area  of,  186 

impulse  at  apex,  changes  in,  172 
Cardiovascular  changes,  171 
Caries  of  spine.  446 
Caseofibroid     phthisis,     chronic,     gross 

appearances,  88 
Cases,  advanced,  physical  signs,  229 

appropriate    for   climatic    change    in 
general,  682 

early,  physical  signs,  219 

with  moderate  involvement,  physical 
signs,  223 
Catheterization,  ureteral,  in  diagnosis  of 

renal  tuberculosis,  495 
Cavernous  breathing,  changes  in  pitch 
and  quality,  207 

rales,  213 

voice.  216 
Cells,  giant-,  79 
.Cerebrospinal  meningitis  and  meningeal 

tuberculosis,  differentiation,  343 
Cervical  glands,  tuberculosis,  418 

and  Hodgkin's  disease,  differen- 
tiation, 420 
diagnosis,  419 
treatment,  429 

lymphatic       tuberculosis,        phtliisis 
following,  101 
Character,    influence    of,   on    prognosis, 

308 
Chemic  composition  of  tubercle  bacillus, 

25 
Chest.     See  Thorax. 
Chest- wall,  retraction  of,  173 
Cheyne-Stokes  type  of  breathing,  157 


765 


Child  labor  in  development  of  tubercu- 
losis, 600 

Circulation,  stasis  in,  122 

Circulatory  disturbances,  120 

Class  system,  tuberculosis,  5S5 

Climate,  affirmative  evidence  in  favor  of, 
671 
arguments    advanced   by    opponents, 

668 
cases  appropriate  for  change  in,  682 
change  of,  influence,  on  prognosis,  311 
errors   of    judgment   in  selection   of, 

670 
explanation  of  not  infrequent  failure 

to  secure  favorable  results,  669 
inconsistencies    of  precept  regarding, 

679 
influence,  on  pulmonary  hemorrhage, 

129 
in  treatment,  clinical  testimony,  679 
physiologic  considerations,  672 
role  of,  667 
popular  localities,  689 
selection    of,    consitlerations    relative 
to,  685 

Clubbed  fingers,  1 16 

Cog-wheel  breathing,  158,  204,  210,  221 

Cold  applications  in  pulmonary  hemor- 
rhage, 720 

Colitis,  mucous,  treatment  of,  708 

Color  of  face,  156 

Colorado,  tuberculosis  indigenous  in, 
extent,  66 

Commercial  establisliments,  hygienic 
construction  and  sanitary  super- 
vision, in  prophylaxis,  605 

Complemental  space,  Gerhardt's,  185 

Complexion,  118 

Complications,  324 
non-tuberculous,  541 

Compulsory  notification,  566 
registration,  506 

Congenital  method  of  infection,  36 

Congestion,  pulmonary,  122 

Conglomerate  tubercles,  79,  83 

Consonating  rales,  212 

Constipation,  treatment,  707 

Consumption.     See  Phthisis. 

Contamination  of  milk,  danger  from, 
597 

Contra-indications  for  excessive  feeding, 
647 

Control,  administrative,  601 


Conveyances,  public,  hygienic  construc- 
tion and  sanitary  supervision,  in 
prophylaxis,  605 

Cornage,  423 

Corpuscle,  tubercle,  18 

Cough,  101 

and  vomiting,  103 
diagnostic  import,  240 
paroxysmal,  107 
stomach,  132 
treatment,  701 

Counterirritation  in  glandular  tubercu- 
losis, 434 

Course,  145 

Cracked-pot  resonance,  190,  231 

Crackling  vesicular  niles,  212 

Creosote  in  phthisis,  725 

Crepitant  rales,  212 

Crude  tubercle,  S3 

Cryoscopy  in  renal  tuberculosis,  496 

Cultural  characteristics  of  tubercle  bacil- 
lus, 22 

Cure,  299 
day,  584 
from  social  standpoint,  563 

Curetment  in  glandular  tuberculosis,  436 
in  vesical  tuberculosis,  502 

Cyanosis  in  pneumonic  type  of  miliary 
tuberculosis,  329 
of  face,  157 

Cystoscopic  examination  of  bladder  in 
renal  tuberculosis,  494 

Cystotomy  in  vesical  tuberculosis,  502 

Cytology  in  tuberculosis  of  pleura,  350 


Day  cure,  584 

resort,  584 
Death,  modes  of,  152 
Death-rate  in  infants,  41 
Degenerative  changes  in  tubercle  deposit, 

81 
Delusions,  137,  138 

Depression,  circumscribed,  of  chest,  168 
Detail,  infinite  regard  for,  in  treatment, 
615 
of  pulmonary  hemorrhage,  714 
Diagnosis,  234 

acceleration  of  pulse,  243 

acquired  predisposition,  237 

aids,  246 

apical  rales,  244 

cough,  240 


766 


641, 


Diagnosis,  differential,  294 

examination  of  sputum,  245 

experiments  on  animals,  251 

exploration  of  chest,  243 

family  history,  236 

fever,  242 

loss  of  weight,  241 

ophthalmotuberculin,  249 

opportunities  for  infection,  237 

present  condition,  240 

previous  disease,  239 

provisional  factors.  236 

Rontgen  rays,  251-293 

tuberculin  test,  247 
Diarrhea,  133 

treatment,  707 
Diet,  physiologic  considerations  i 
642 

regulation  of,  in  treatment,  039 
Digestive  apparatus,  symptoms  referable 
to,  131 

disorders,  treatment,  704 

tract,  infection  through,  51 
Diseases  predisposing  to  tuberculosis,  75 

pre\nous,  diagnostic  import,  239 
Disinfection,  formaldehyd,  of  sick-room, 

575 
Dispensary,  583 

Displacement   of   heart    in   tuberculosis 
of  pleura,  358 

of   organs   in   tuberculosis  of  pleura, 
358 
Disposition,  influence,  on  prognosis,  308 
Distribution  of  tubercle  bacilli,  55 
Domiciliary  visitation,  585 
Droplet  infection,  43 
Drugs,  723 

in  pulmonary  hemorrhage,  717 
Dry  bronchial  rales,  212 

tracheal  rale,  21 1 

vesicular  rales,  212 
Dulness,  177 

cardiac,  area  of,  185 
Dyspepsia,  nervous,  132,  649 

treatment.  704 
Dyspeptic  type,  100 
Dyspnea,  109 

in  pneumonic  type  of  miliary  tuber- 
culosis, 329 


Ear,  tuberculosis  of,  535 
Early  cases,  physical  signs,  219 


Edema  of  ankles,  123 

of  face,  123,  157 

of  feet,  123 

of  hands,  123 

of  lungs,  122 
Education  and  supervision,  571 
Educational  literature,  590 

distribution,  591 
Effusion,     serous,     in    tuberculosis     of 
pleura,       aspiration      for, 
indications     and     contra- 
indications, 368 
rules,  370 
treatment,  366 
Eggs  in  treatment.  646 
Egophony,  216 
Electrolysis   in    glandular    tuberculosis, 

434 
Emaciation,  115 
Emphysematous  chest,  162 

respiration,  204 
Empyema,  373 

clinical  manifestations,  373 

exploratory  puncture  in,  374 

necessitatis,  374 

treatment,  376 
Endocarditis,  122 

Energy,  conservation  of,  in  treatment, 
619 

nervous,  142 
Environment,  relation,  to  infection,  73 

social,  influence  on  prognosis,  310 
Epididymis,  tuberculosis  of,  488,  506 
diagnosis.  507 
treatment,  508 
Epigastric  pulsation,  173 
Epiglottis,  turban-shaped,  532 
Esophagus,  tuberculosis  of,  464 
Etiology,  17 

Ewart's  sign  in  tuberculosis  of  pericar- 
dium, 398 
Examination     of     sputum,     diagnostic 

import,  245 
Excessive  feeding  in  treatment,  641 

contraindications,  647 
Excision  in  glandular  tuberculosis,  436 
Exercise  in  treatment.  620 
Exhibitions,  instruction  in  prophylaxis 

through,  592 
Expectoration,   103.     See  also  Sputum. 
Experiments     on     animals,     diagnostic 

import,  251 
Expiration,  prolongation.  209 


767 


Exploration  of  chest,  diagnostic  import, 

243 
Exploratory  puncture  in  empyema,  374 
Extension  of  material  aid  according  to 

varying    needs    and   requirements   of 

differing  classes,  576 
Extremities,   ligation  of,   in  pulmonary 

hemorrhage,  722 
Eye,  tuberculosis  of,  540 


Face,  appearance  of,  118,  156 
color  of,  156 
cyanosis  of,  157 
edema  of,  123,  157 
Fallopian  tubes,  tuberculosis,  488,  511 
symptoms,  512 
treatment,  512 
Family  history,  diagnostic  import,  236 


Fatigue,  avoidance  of,  in  treatment,  619 

Feeding,  excessive,  in  treatment,  641 
contraindications,  647 

Feet,  edema  of,  123 

Fever,  111 

clinical  types,  113 
diagnostic  import,  242 
hectic,  113 

in  pneumonic  type  of  miliary  tubercu- 
losis, 329 
of  absorption,  113 
temperature  during,  113 

Fibroid  phthisis,  148 

chronic,  gross  appearances,  91 

Financial  condition,  influence  on  prog- 
nosis, 309 

Finger,    pleximeter,    position,    in    per- 
cussion, 180 

Fingers,  appearance  of,  116 
clubbed,  116 

Fistula,  rectal,  484 
treatment  of,  485 

Flatness,  cardiac,  area  of,  186 
percussion,  absence  of,  187 

Food,  character  of,  to  be  substituted  for 
human  milk,  596 

Food-supply,  inspection  of,  in  prophy- 
laxis, 603 

Formaldehyd  disinfection  of  sick-room, 
575 

Fowler's  solution  in  phtliisis,  724 

Fremitus,  vocal,  174 
diminished,  175 


Fremitus,  vocal,  increased,  175 

Friction-sounds,  pericardial,  176 
pleural,  176 

Friedreich's    sign    in    adherent    pericar- 
dium, 404 

Funnel  breast,  165 

Furniture  of  sick-room,  574 


Galloping  consumption,  95 
Gastric  disturbances,  131 
Gastro-intestinal  tract,  infection  through, 

51 
Genito-urinary  symptoms,  142 
tract,  tuberculosis  of,  487 
etiology,  487 
in  children,  489 
in  female,  511 
Geograpliic  distribution,  influence  of,  65 
Gerhardt's  change,  of  pitch,  191 

complemental  space,  1 85 
Giant-cells,  79 

Glands,  bronchial,  tuberculosis  of,  415 
treatment,  429 
cervical,  tuberculosis  of,  418 

and  Hodgkin's  disease,   differen- 
tiation, 420 
diagnosis,  419 
treatment,  429 
lymphatic  tuberculosis  of,  412 

treatment,  429 
mediastinal,  tuberculosis  of,  422 
clinical  manifestations,  422 
physical  signs  of  bronchial  com- 
pression in,  423 
of    tracheal   compression  in, 
423 
roaring  in,  424 
treatment,  429 
mesenteric,  tuberculosis  of,  428 

treatment,  429 
tuberculosis  of,  412.     See  also  Glan- 
dular tuberculosis. 
Glandular  tuberculosis,  412 
aspiration  in,  435 
counterirritation  in,  434 
curetment  in,  436 
electrolysis  in,  434 
excision  in,  436 
hygienic  treatment,  429 
incision  in,  435 
massage  in,  434 
medicinal  treatment,  433 


768 


Glandular     tuberculosis,     pathogenesis, 
412 
surgical  treatment,  435 
treatment,  429 
general,  429 
hygienic,  429 
local,  434 

non-operative,  434 
medicinal,  433 
surgical,  435 
x-rays  in,  434 
Gross  appearances,  85 
Gums,  tuberculosis  of,  463 
Gymnastics,  pulmonary,    in    treatment, 
623 


Hallucinations,  138 
Hands,  edema  of,  123 

tubercle  bacilli  on,  514 
Harsh  respiration,  221 
Heart,    apex    of,    cardiac    impulse    at, 
changes  in,  172 
displacement    of,    in    tuberculosis    of 

pleura,  358 
weakness  of,  121 
treatment,  710 
Hectic  fever,  113 
Hemorrhage,  pulmonarj',  123.     See  also 

Pulmonary  hemorrliage. 
Hereditary  syphilis,  555 

transmission,  36 
Hip-joint,    tuberculosis    of,    symptoms, 

450 
Histology,  78 
Historic  review,  18 

History,  family,  diagnostic  import,  236 

influence,  of,  on  prognosis,  306 

of    present    illness,    influence    of,    on 

prognosis,  312 
previous,   influence   of,   on   prognosis, 
306 
Hoarseness,  108 
Hodgkin's   disease  and  tuberculosis  of 

cervical  glands,  differentiation,  420 
Houses,  tenement,  hygienic  construction 
and  sanitary  super\'ision,  in  propliy- 
laxis,  605 
Hygiene,  proper,  in  prophylaxis,  600 
Hygienic  treatment  of  glandular  tuber- 
culosis, 429 
of  tuberculosis  of  bones  and  joints, 
457 


Hyperplastic    form    of    tuberculosis    of 
intestine,  469 
of  vermiform  appendix,  471,  473 


Ice-bag  in  pulmonarj'  hemorrhage,  720 
Illness,    present,    history    of,    influence, 

on  prognosis,  312 
Immunity  and  bacteriolysis,  732 
and  opsonins,  733 
and  tuberculin,  727 
apparent,   evidence   of,   in    prognosis, 

315 
theories  of,  726 
Incision  in  glandular  tuberculosis,  435 
Indeterminate  rales,  214 
Indians,  tuberculosis  in,  61,  75 
Indigestion,  131,  647 

gastric,  acute,  treatment  of,  704 
chronic,  treatment  of,  705 
Industrial  pursuits  in  State  sanatoria, 

581 
Infants,  death-rate  in,  41 

protection  of,  from  tuberculous  infec- 
tion, 596,  597 
Infection,   conditions   influencing,   after 
exposure  to  tubercle  bacillus,  72 
congenital  method,  36 
droplet,  43 
hereditarj',  36 
inhalation,  43 
intra-uterine,  38 
latent  imsuspected,  99 
mixed,  113,  541 

antistreptococcic  serum  in,  547 
bacterial  vaccines  in,  549 
prognosis  of,  546 
treatment  of,  547 
opportunities  for,   diagnostic  import, 

237 
postnatal,  dangers  of,  596 
relation  of  environment  to,  73 
role  of  skin  as  channel  for,  513 
through  alimentary  tract,  51 
digestive  tract,  51 
gastro-intestinal  tract,  51 
intestinal  tract,  51 
respiratory  tract,  43 
Infectious   diseases,    phthisis   following, 

101 
Infinite  details,  regard  for,  in  treatment, 
615 
of  pulmonary  hemorrhage,  714 


7fio 


Influence  of  age  on  prognosis,  301 
of  family  history  on  prognosis,  306 
of  geographic  position,  65 
of  race,  59 

on  prognosis,  304 
of  sex  on  prognosis,  303 
Influenza,  99 

and  meningeal  tuberculosis,  differen- 
tiation, 345 
Inhalation  infection,  43 
Inherited  predisposition,  72 
Insanity,  138 
Insomnia,  139 

treatment,  710 
Inspection,  155 

conditions     independent     of     thorax 

noted,  156 
of  thorax,  158 
rules  for,  155 
Inspiration,  shortening,  209 
Institutions,  577 

for  hopelessly  ill  and  impoverished,  577 
for  poor  consumptives,  579 
for  vicious  patients,  578 
Intelligence,  influence  of,  on  prognosis, 

308 
Intercostal  neuralgia  in  phthisis,  107 
Intestinal  symptoms,  133 

toxemia,  acute,  treatment  of,  708 
and  meningeal  tuberculosis,  differ- 
entiation, 345 
tract,  infection  through,  51 
Intestine,  tuberculosis  of,  466 
hyperplastic  form,  469 
pathologic  features,  468 
treatment,  470 
ulcerative  type,  468 
Intra-uterine  infection,  38 
Introduction,  17 
Irish,  tuberculosis  in,  63 


Joints,  tuberculosis  of,  440 
Bier  treatment,  460 
clinical  manifestations,  444 
microscopic  pathology,  443 
pathology,  440 
prognosis,  446 
symptoms,  early,  444 
treatment,  457 

hygienic,  457 

local,  458 

non-operative  measures,  459 


Joints,  tuberculosis  of,  treatment,  surgi- 
cal, 461 
tuberculous  abscess  in,   treatment, 
461 
Jousset's  method  of   diagnosing  tuber- 
culosis of  pleura,  350 
Jiirgensen's  sign  in  tuberculosis  of  pleura, 
356 


Kidney,  tuberculosis  of,  487,  490 

cryoscopy  in,  296 

cystoscopic  examination  of  bladder 
in,  494 

diagnosis,  493 

frequent  micturition  in,  492 

nephrectomy  in,  498 

nephrotomy  in,  498 

pain  in,  492 

pathology,  491 

phlorizin  test  in,  496 

prognosis,  496 

segregation  of  urine  in  diagnosis,  495 

symptoms,  492 

treatment,  496 

ureteral  catheterization  in  diagnosis, 
495 

urine  in,  492 

x-rays  in  diagnosis,  495 
Knee-joint,  tuberculosis  of,  symptoms, 
454 


Labor,  cliild,  in  development  of  tuber- 
culosis, 600 
La  grippe,  99 

and  meningeal  tuberculosis,  differen- 
tiation, 345 
Laryngeal  manifestations,  100 
Larynx,  tuberculosis  of,  524 
etiology,  526 
prognosis,  532 
symptoms,  local,  531 

subjective,  530 
treatment,  533 
vocal  resonance  over,  203 
Latent  unsuspected  infection,  99 
Lectures,     instruction     in     prophylaxis 

through,  592 
Lepra    bacillus    and    tubercle    bacillus, 

resemblance,  21 
Ligation   of   extremities   in   pulmonary 
hemorrhage,  722 


770 


Linen,  care  of,  574 

Lingula  pulmonalis,  172,  184 

Literature,  educational,  590 

distribution  of,  591 
Litten's  phenomenon,  170 
Lobar  phthisis,  acute,  gross  appearances, 

87 
Lobular     phthisis,     acute,     pathologic 

appearances,  88 
Loss  of  weight,  diagnostic  import,  241 
Lungs,  active  mobility,  185 

passive  mobility,  185 

vocal  resonance  over,  203 
Lupus  verrucosa,  513 

vulgaris,  522 
Lymphatic  glands,  tuberculosis,  412 
treatment.  429 

system    in    development    and    spread 
of  tuberculosis,  412 

tuberculosis,  cervical,  plithisis  follow- 
ing, 101 


Macroscopic  appearance  of  epididymis 
and  testis,  506 
of  tuberculosis  of  appendix,  hyper- 
plastic type,  473 
of  tuberculous  pulmonary  le-sions,  85 
Marriage  of  tuberculous  individuals.  595 
Massage  in  glandular  tuberculosis,  434 
Measles,  phthisis  following.  101 
Mediastinal  glands,  tuberculosis.  422 
clinical  manifestations.  422 
physical  signs  of  bronchial  com- 
pression in.  423 
of   tracheal   compression   in, 
423 
roaring  in,  424 
treatment,  429 
Medical     practice,     restriction     of,     in 

prophylaxis,  604 
Medicines,    patent,    control    of,    in   pro- 
phylaxis, 604 
Membrane,  pyogenic.  90 
Meningeal  form  of  miliar}'  tuliorculosis. 
335.     See     also     Meningeal     liiher- 
culosis. 
tuberculosis,  335 

and  cerebrospinal  meningitis,  differ- 
entiation, 343 
and  influenza,  differentiation.  345 
and  intestinal  toxemia,  differentia- 
tion. 345 


Meningeal  tuberculosis   and  middle-ear 
disease,  differentiation,  344 
and  pneumonia,  differentiation,  344 
and  typhoid  fever,   differentiation, 

344 
diagnosis,  differential,  342 
patliogenesis,  335 
pathologic  changes,  336 
symptoms,  337 
in  adults,  338 
in  children  from  two  to  six  years 

of  age,  340 
in  infants,  342 
tache  cerebrale  in,  341 
treatment,  346 
Meningitis,  cerebrospinal,  and  meningeal 

tuberculosis,  differentiation.  343 
Mental  disturbances  during  pulmonary 
liemorrhage,  127 
effect  of  pulmonary  hemorrhage.  713 
symptoms.  135 
Mentality,  perverted.  137 
Mesenteric  glands,  tuberculosis,  428 

treatment,  429 
MetaUic  rales,  214 
Metamorphosing  respiration.  208 

changes  in  pitcli  and  quality,  208 
Micturition,    frequent,    in    renal    tuber- 
culosis. 492 
Middle-ear  tlisease  and  meningeal  tuber- 
culosis, differentiation,  345 
Miliary  tuberculosis,  324 

general  considerations,  324 

gross  appearances,  87 

meningeal     form,     335.     See     also 

Meningeal  tuberculosis. 
pneumonic  type,  329 
cyanosis  in.  329 
dyspnea  in.  329 
fever  in.  329 
method  of  onset,  96 
typhoid  type.  331 

differentiation     from     typhoid 
fever.  332,  333 
Milk,  contamination  of,  danger  from,  597 

in  treatment.  650 
Miner's   phthisis,    differential    diagnosis, 

294 
Mixed  infection,  113.  541 

antistreptococcic  serum  in,  547 
bacterial  vaccines  in,  549 
prognosis,  546 
treatment,  547 


771 


Mobility,  active,  of  lungs,  185 

passive,  of  lungs,  185 
Moderate  involvement,  intensification  of 
whispered  voice  in,  228 
physical  signs,  223 
Moist  bronchial  rdles,  211 
Moisture,  disadvantages  of,  in  treatment, 

674 
Monomania,  138 

Morphin  in  pulmonary  hemorrhage,  718 
Mucous  colitis,  treatment,  708 

membrane,  buccal,  tuberculous  lesions 

of,  462 
rMes,  211,  212 


Neck,  visible  changes  in,  173 
Necrogenic  wart,  513,  521 
Negro,  tuberculosis  in,  60,  74 
Nephrectomy  in  renal  tuberculosis,  498 
Nephritic  disturbances,  143 
Nephritis,  144 

Nephrotomy  in  renal  tuberculosis,  498 
Nervous  energy,  142 

disturbances  after  pulmonary  hemor- 
rhage, treatment  of,  714 
during  pulmonary  hemorrhage,  127 

dyspepsia,  132,  649 

effort,  adjustment,  in  treatment,  619 

individuals,  pain  in,  108 

symptoms,  135 

system,  influence  of  altitude  on,  678 
Neuralgia,  intercostal,  in  phthisis,  107 
Neuroses,  functional,  gastric,  131 

treatment  of,  706 
Night-sweats,  treatment,  709 
Non-consonating  rales,  211 
Non-tuberculous  complications,  541 
Nose,  tuberculosis  of,  538 
Notification,  compulsory,  566 
Nummular  sputum,  104 
Nutrition,     impaired,     tuberculosis     in 
infants  from,  597 
tuberculosis  in  school-children  from, 


Objective  symptoms,  local,  1 16 
Occupation,  influence,  on  prognosis,  307 

predisposing  to  tuberculosis,  75 
Onset,  acute,  94 
septic,  98 

anemic,  100 


Onset,  bronchial,  99 
hemorrhagic,  97 
method  of,    94 
non-acute,  94,  99 
Open-air  existence,  comfort  and  shelter 
in,  629 
enforcement  of,  626 
Ophthalmotuberculin  reaction,  249 
Opsonins  and  immunity,  733 
Oral  tuberculosis,  462 
Osteomyelitis,  tuberculous,  443 
Otitis  media,  tuberculous,  535 
Overfeeding  in  treatment,  641 
contraindications,  647 


Pain,  106 

in     acute     bronchitis     complicating 

phtliisis,  107 
in  chest,  106 

in  head  in  meningeal  type  of  miliary 
tuberculosis,  338,  340 
in  typhoid  type  of  miliary  tuber- 
culosis, 331,  332 
in  nervous  individuals,  108 
n  renal  tuberculosis,  492 
n  tuberculosis  of  appendix,  473 
of  bladder,  500 

of  bones  and  joints.  445, 446, 450, 451 
of  epididymis,  acute,  507 
of  initial  pneumothorax,  107 
resulting  from  pleuritic  involvement, 
107 
Palate,  soft,  tuberculosis  of,  463 
Palpable  rhonchi,  176 
Palpation,  174 

of  blood-vessels,  176 
Paralytic  chest,  159 
Paroxysmal  cough,  107 
Patent  medicines,  control  of,  in  prophy- 
laxis, 604 
Pathologic  anatomy,  17,  76 
conditions,  auscultation  in,  203 
percussion  in,  186 
Pectoriloquy,  216 
Percussion,  177 

avoidance  of  instruments,  179 
boundaries,  185 
flatness,  absence,  187 
in  abnormal  states,  186 
manner  of  dealing  blow,  181 
of  chest,  182 

regional  differences,  182 


772 


Percussion,  position  of  examiner,  1S2 

of  pleximeter  finger,  180 
resonance,  177.     See  also  Resonance. 
rules  for  patient,  179 

for  physician,  179 
Pericardial  friction-sounds,  176 
Pericardium,  adherent,  403 

Broadbent's  sign  in,  404 

Friedreich's  sign  in,  404 
tuberculosis  of,  395 

Bamberger's  sign  in,  398 

course,  399 

diagnosis,  399 

etiologic  and  patliologic  data,  395 

Ewart's  sign  in,  398 

prognosis,  399 

Rotch's  sign  in,  398 

symptoms,  397 

treatment,  402 

varieties,  396 
Peritoneum,  tuberculosis  of,  404 

diagnosis,  408 

etiologic  relations,  405 

pliysical  examination  in,  408 

prognosis,  410 

symptoms,  407 

treatment,  411 
Perle  disease,  29 
Personal  equation  in  medical  supervision, 

influence  of,  on  prognosis,  310 
Perverted  mentality,  137 
Pharynx,  tuberculosis  of,  463 
Phlorizin  test  in  renal  tuberculosis,  496 
Phthisical  chest,  161 

habitus,  18 
Phthisis  florida,  95 

Physical    effort,  adjustment,   in    treat- 
ment, 619 
signs,  154,  218 

general,  155 

in  advanced  cases,  229 

in  early  cases,  219 

in  moderate  involvement,  223 

in  prognosis,  313 
Physician,    instruction    in    prophylaxis 

through,  593 
Pigeon-breast,  163 
Pitch,  178 

changes  in,  190 
Gerhardt's  change  of,  191 
Wintrich's  change  of,  190 
Pleura,  tuberculosis  of,  347 

cytology  in,  350 


Pleura,  tuberculosis  of,  diagnosis,  363 
displacement  of  heart  in,  358 

of  organs  in,  358 
etiology,  348 

Jousset's  method  of  diagnosing,  350 
Jiirgensen's  sign  in,  356 
pathologic  changes,  351 
pathology,  348 
prognosis,  365 

serous   effusion   in,   aspiration   for, 
indications     and     contra- 
indications, 368 
rules,  370 
treatment,  368 
symptoms,  353 
Pleural  friction-sounds,  176 

rules,  213 
Pleurisy,  acute,  98 

phthisis  following,  101 
Pleuritic    involvement,     pain    resulting 

from,  107 
Pleximeter   finger,   position   of,   in   per- 
cussion, 180 
Pneumonia  and  meningeal  tuberculosis, 
differentiation,  344 
phthisis  following,  101 
Pneumonic   acute   miliary  tuberculosis, 
method  of  onset,  96 
consolidation,  85 
phthisis,  acute,  gross  appearances,  87, 

method  of  onset,  95 
lobular,  gross  appearances,  88 
type  of  miliary  tuberculosis,  329 
cyanosis  in,  329 
dyspnea  in,  329 
fever  in,  329 
Pneumonokoniosis,  149 
Pneumopyothorax.  389 
physical  signs,  389 
treatment,  390 
Pneumothorax,  383 


initial  pain  of,  107,  384 

percussion,  385 

physical  signs,  383 

prognosis,  386 

symptoms,  383 

treatment,  387,  388 

varieties,  383 
Porch  in  treatment,  632 
Postnatal  infection,  danger; 
Pott's  disease,  446 


Precordia,  changes  in,  171 
Predisposition,  acquired, 
import,  237 
inherited,  72 
Pregnancy,  549 
Present  illness,  history,  influence  of,  on 

prognosis,  312 
Prevalence,  57 

Prevention,  560.     See  also  Prophylaxis. 
Previous  history,  influence,  on  prognosis, 

306 
Primary  involvement,  site  of,  92 
Prognosis,  299 
age,  301 
change  of  surroundings  and  climate, 

311 
character,  308 

of  systemic  disturbance,  316 
disposition,  308 

evidence  of  apparent  immunity,  315 
factors  pertaining  to  individual,  300 
family  lustory,  306 
financial  condition,  309 
history  of  present  illness,  312 
intelligence,  308 
occupation,  307 

personal   equation  in   medical   super- 
vision, 310 
physical  signs,  313 
previous  history,  306 
race,  304 
sex,  303 

social  environment,  310 
temperament,  308 
Prophylaxis,  560 

administrative  control,  601 
authentic   official  information  to  gen- 
eral public  regarding,  586,  595 
compulsory  notification  and  registra- 
tion, 566 
control  of  patent  medicines  in,  604 

of  sputum  in,  602 
education  of  consumption.  571 
extension  of  material  aid  to  differing 

classes,  576 
hygienic    con.struction    and    sanitary 
supervision  of  commercial 
establishments  in,  605 
of  public  buildings  and  con- 
veyances, '605 
of  tenement  houses  in,  605 
of  workshops  or  factories  in, 
605 


!  Prophylaxis  in  infants,  596,  597 

in  school-cliildren,  599 
1       inspection  of  food-supply  in,  603 
institutions  for  consumptives,  577 
instruction  in,  through  exhibitions,  592 
lectures,  592 
physician,  593 
public  schools,  589 
publications,  590 
proper  hygiene  in,  600 
reciprocal   relations   of  consumptives 

and  society,  560 
regulation  of  schools  in,  602 
restriction  of  medical  practice  in,  604 
State  Sanatoria,  579 
supervision  of  consumptive   and   his 

environment,  571 
what  the  public  should  know,  597 
Prostate,  tuberculosis  of,  488,  504 
symptoms,  504 
treatment,  505 
Provisional  diagnostic  factors,  236 
Public  buildings,   hygienic  construction 
and  sanitary  supervision  in  prophy- 
laxis, 605 
conveyances,     hygienic     construction 
and  sanitary  supervision  in  prophy- 
laxis, 605 
general,  authentic  official  information 
to,    regarding    prophylaxis,    586, 
595 
instruction      in     prophylaxis     to, 
through  exhibitions,  592 
lectures,  592 
physician,  593 
public  schools,  589 
publications,  590 
schools,    instruction    in    propliylaxis 
through,  589 
Publications,  instruction  in  prophylaxis 

through,  590 
Puerile  respiration.  205 
Pulmonary  congestion,  122 
edema,  122 

gymnastics  in  treatment,  623 
hemorrhage,  123 
atropin  in.  719 
bronchopneumonia  after,  treatment, 

719 
cold  applications  in,  720 
constriction  of  chest  in,  722 
during  sleep,  125 
histology,  84 


774 


Pulmonary  hemorrhage,  ice-bag  in,  720 
immediate  effects,  127 
influence  of  climate  on,  129 
initial,  method  of  onset,  97 
hgation  of  extremities  in,  722 
moderate,  125 
morphin  in,  718 
nervous    and    mental    disturbances 

during  and  after,  127,  713,  714 
remote  effects,  128 
severe.  126 
treatment,  711 
drugs  in,  717 

general  considerations,  713 
regard  for  detail,  714 
special  methods,  720 
venesection   and    salt    solution    in, 
720 
Pulsation,  epigastric,  173 
Pulse,  acceleration  of,  120 
diagnostic  import,  243 
irregularity  of,  121 
Puncture,  exploratory,  in  empyema,  374 
Pyogenic  membrane,  90 


Race,  influence  of,  59 

on  prognosis,  304 
Rachitic  chest,  163 

rosary,  164 
Rfiles,  210 

apical,   unilateral,  diagnostic  import, 

244 
bronchial,  dry,  212 

moist,  211 
cavernous,  213 
consonating,  212 
crepitant,  212 

in  diagnosis  of  early  cases,  220 
indeterminate,  214 
metallic,  214 
mucous,  211,  212 
non-conscnating,  211 
pleural,  213 
resonant,  212 
subcrepitant,  212 
succussion,  214 
tracheal,  210 

dry,  211 
vesicular,  212,  213 

crackling,  212 

dry,  212 
Receptacle  for  sputum,  573 


Reciprocal  relations  of  consumptives  and 

society,  560 
Recovery,  299 

Recreation  in  treatment,  621 
Rectal  fistiUa,  484 

treatment,  485 
Red  blood-corpuscles,  influence  of  alti 

tude  on,  676 
Registration,  compulsory,  566 
Renal  tuberculosis,  487,  490.     See  also 

Kidney,  tuberculosis  of. 
Resonance,  177 
absence  of,  187 
amphoric,  189 
changes  in  intensity,  188 

in  quality,  188 
cracked-pot,  190,  231 
duration  of.  178 
quality  of.  178 
tympanitic.  178,  188 
vesicular.  178 

vocal,  changes  in  intensity,  215 
in  pitch  and  quality,  216 
increased.  215 

modifications,  in  disease,  215 
over  larynx.  203 
over  lung.  203 
over  trachea.  203 
suppression  or  diminution,  215 
Resonant  nlles.  212 
Resort,  day,  584 

Respiration,  amphoric,  changes  in  pitch 
and  quality,  208 
asthmatic,  204 
bronchial,  auscultation  of,  200 

changes  in  pitch  and  quality,  206 
bronchocavernous.  208 
bronchovesicular,  202 

changes  in  pitch  and  quality,  206 
cavernous,     changes     in     pitch     and 

quality,  207 
Cheyne-Stokes  type,  157 
cog-wheel.  158,  204,  210,  221 
emphysematous.  204 
frequency  and  character,  157 
harsh,  221 
metamorphosing,  208 

changes  in  pitch  and  quality,  208 
puerile.  205 
restrained.  1,58 
rhythm  and  sound,  157 
sighing,  158 
stridulous,  158 


775 


Respiration,   vesicular,  auscultation  of, 
199,  200 
regional  differences,  201 
vesiculocavernous,  208 
Respiratory  movements,  169 

rate,  influence  of  altitude  on,  678 
sounds,  absence  of,  204 
auscultation  of,  199 
clianges  in  duration,  209 
in  intensity,  204 
in  pitch  and  quality,  206 
in  rhythm,  210 
diminution  of  intensity,  204 
increased  intensity,  205 
modification,  203 
tract,  infection  through,  43 
upper,  tuberculosis  of,  524 
Rest  in  treatment,  619 
Restrained  respiration,  158 
Reticulum  of  elementary  tubercle,  80 
Retraction  of  chest- wall,  173 

unilateral,  of  chest,  167 
Revolving  shelter  in  treatment,  636 
Rhonchi,  palpable,  176 
Roaring  in  tuberculosis  of  mediastinal 

glands,  424 
Rontgen  rays,  diagnostic  import,  251- 
293 
in  diagnosis  of  renal  tuberculosis,  495 
in  treatment  of  glandular  tubercu- 
losis, 434,  435 
Rosary,  rachitic,  164 
Rotch's  sign  in  tuberculosis  of  pericar- 
dium, 398 


Salt  solution   and  venesection   in   pul- 
monary hemorrhage,  720 
Sanatoria,  scope  of,  in  treatment,  651 
State,  579 

industrial  pursuits  in,  581 
influence  of,   on   neighboring   com- 
munities and  surrounding  prop- 
erty, 581 
tuberculosis  in,  41 
prophylaxis,  598 
Schools,  public,  instruction  in  prophy- 
laxis through,  589 
regulation  of,  in  prophylaxis,  602 
Scrofuloderma,  513,  522 
Segregation  of  urine  in  diagnosis  of  renal 

tuberculosis,  495 
Semilunar  space,  Traube's.  184 


Seminal  vesicles,  tuberculosis  of,  505 
Septic  disturbances,  acute,  98 
Serous  effusion  in  tuberculosis  of  pleura, 
aspiration  for,  indications 
and  contraindications,  368 
rules,  370 
treatment,  366 
Serum,  antistreptococcic,  in  mixed  infec- 
tion, 547 
Serum,  Maragliano's,  730,  731 
Sex,  influence  of,  on  prognosis,  303 
Sexual  desire,  144 

organs,  144 
Sick-room,  formaldehyd  disinfection  of, 
575 
furniture  of,  574 
Sighing  respiration.  158 
Sign,    Bamberger's,    in    tuberculosis    of 
pericardium,  398 
Broadbent's,  in  adherent  pericardium, 

404 
E wart's,    in   tuberculosis   of   pericar- 


:ich's,  in  adherent  pericardium, 
is  of  pleura, 
of    pericar- 


Friedn 

404 
Jiirgensen's,  in  tuberculo 

356 
Rotch's,    in    tuberculosis 
dium,  398 
Signs,  physical,  218 

in  advanced  cases,  229 
in  early  cases,  219 
in  modern  involvement,  223 
in  progno.sis,  313 
Site  of  primary  involvement,  92 
Skin,  condition  of,  in  tuberculosis,  116 
role   of,    as   channel    for    tuberculous 

infection,  513 
tuberculosis  of,  513 
diagnosis,  523 
prognosis,  523 
scrofulous  type,  522 
treatment,  524 
ulcerative  form,  521 
varieties,  521 
verrucous  variety,  521 
Sleep,  disturbed.  139 

pulmonary  hemorrhage  during,  125 
Sleeping  canopy.  629 
Sleeplessness,  139 

treatment  of,  710 
Social  environment,  influence,  on  prog- 
nosis, 310 


776 


Society    and    consumptives,    reciprocal 

relations,  560 
Soft  palate,  tuberculosis,  463 
Soldiers,  tuberculosis  in,  75 
Sounds,  respiratory,  absence  of,  204 
auscultation  of,  199 
changes  in  duration,  209 
in  intensity,  204 
in  pitch  and  quality,  206 
in  rhythm,  210 
diminution  of  intensity,  204 
increased  intensity,  205 
modification  of,  203 
voice-,  202 
Space,  Gerhardt's  complemcntal,   185 

Traube's  semilunar,  184 
Specific  treatment,  720 
Spine,  caries  of,  440 
Spoken  voice,   modifications  of,  in  tlis- 

ease,  215 
Sputum,  blood  in,  104,  124 
care  of,  572 
composition  of,  105 
control  of,  in  prophylaxis,  602 
examination  of,  diagnostic  import,  245 
gross  appearances,  104 
nummular,  104 
quantity,  103 
receptacle  for,  573 
sterilization  of,  573 
Staining  tubercle  bacillus,  20 
Stasis  in  circulation,  122 
State,  duty  of,  to  tuberculosis,  563 
sanatoria,  579 

industrial  pursuits  in,  581 
influence  of,   on  neighboring  com- 
munities and  surrounding  proper- 
ties, 581 
Sterilization  of  sputum,  573 
Stethoscope,  auscultation  with,  193 
Bowies',  197 
Camman's,  194 
Stomach  cough,  132 
symptoms,  131 
tuberculosis  of,  465 
Stridulous  breathing,  158 
Strychnin  in  phthisis,  724 
Subcrepitant  rAles,  212 
Submiliary  tubercles,  79,  83 
Succussion  rales,  214 
Suction  pull,  93 

Sunlight,  effect  of,  on  tubercle  bacillus, 
23 


Supervision  and  education,  571 
Surroundings,  change  of,    influence   on 

prognosis,  311 
Sweats,  night-,  treatment  of,  709 
Swedes,  tuberculosis  in,  63 
Symptoms,  94 

cough  and  expectoration,  101 
emaciation  and  local  objective  symp- 
toms, 115 
fever,  111 

methods  of  onset,  94-101 
pain,  hoarseness,  and  dyspnea,  106 
referable  to  circulation,  120 
to  digestive  apparatus,  131 
to  genito-urinary  tract,  142 
to  mind  and  nervous  system,  135 
special,  treatment  of,  701 
Syphilis,  555 

already  existing,  modifying  action  of 

tuberculosis  on,  557 
and    phthisis,    differential    diagnosis, 

296,  558 
hereditary,  555 

influence  of.   on   previously  acquired 
tuberculosis,  556 
on   vulnerability   of  the  tissues  to 
future  tuberculous  infection,  556 
Systemic  disturbances,  character,  influ- 
ence of,  on  prognosis,  316 


TO  tuberculin,  728 

TR  tuberculin,  728 

Tache  cer^brale  in  meningeal  tuberculo- 
sis, 341 

Tacliycardia,  120 

Temperament,  influence,  on  prognosis, 
308 

Temperature,  clinical  types  of  fever,  1 13 

Tenement  houses,  hygienic  construction 
and  sanitary  supervision,  in  prophy- 
laxis, 605 

Tent  life  in  treatment,  632 
window-,  Knopf's,  627 

Termination,  152 

Test,  ophthalmo-tuberculin,  249 
phlorizin,  in  renal  tuberculosis,  496 
tuberculin,  247 

Testes,  tuberculosis  of,  506 
diagnosis,  507 
treatment,  508 

Thorax,  au.'icultation  of,  199 
barrel,  163 


777 


Thorax,  circumscribed  depression,  168 
prominences,  168 
conditions  independent  of,   noted  on 

inspection,  156 
constriction  of,  in  pulmonary  hemor- 
rhage, 722 
emphysematous,  162 
exploration  of,  diagnostic  import,  243 
inspection  of,  158 
pain  in,  106 
paralytic,  159 
percussion  of,  182 

regional  differences,  182 
phthisical,  161 
unilateral  prominence,  167 

retraction,  167 
rachitic,  163 
size  and  shape,  159 
Tirage,  423 
Tissues,    character    of,    as    determining 

course  of  tuberculosis,  76 
Tone,  William's  tracheal,  189 
Tongue,  tuberculosis  of,  463 
Tonsils  as  port  of  entrance  for  tubercle 
bacillus,  415 
tuberculosis  of,  464 
Toxemia,  intestinal,  acute,  treatment  of, 
708 
and  meningeal  tuberculosis,  differ- 
entiation, 345 
of  pneumonia  and  meningeal   tuber- 
culosis, differentiation,  344 
Trachea,  vocal  resonance  over,  203 
Tracheal  compression,  physical  signs,  in 
tuberculosis   of  mediastinal  glands, 
423 
rates,  210 
dry,  211 
tone,  William's,  189 
Transmission,  562 

hereditary,  36 
Traube's  semilunar  space,  184 
Treatment,  612 

adjustment  of  physical   and   nervous 

effort,  619 
alcohol,  646 

avoidance  of  fatigue,  619 
climate,  clinical  testimony,  679 
physiologic  considerations.  672 
role  of,  667 
conservation  of  energy,  619 
diet,  regulation  of,  639 
disadvantages  of  moisture,  674 


Treatment,  eggs,  646 
excessive  feeding,  643 

contraindications,  647 
exercise,  620 
general,  560 

considerations,  612 
King's  lean-to  arrangement,  636 
Knopf's  window-tent,  627 
milk,  650 

of  special  symptoms,  701 
open-air  existence,  comfort  and  shelter 
in,  629 
enforcement  of,  626 
overfeeding,  641 

contraindications,  647 
porch,  631,  632 
principles  of,  614 
pulmonary  gymnastics,  623 
recreation,  621 
regard  for  infinite  detail,  615 
regulation  of  diet,  639 
rest  in,  619 
revolving  shelter,  636 
role  of  climate,  667 

clinical  testimony,  679 
physiologic  considerations,  672 
sanatorium,  scope  of,  651 
sleeping  canopy,  629 

porches,  631,  632 
specific,  560,  726 
tent  life,  632 
walking  in  open  air,  621 
wooden  shelters,  633 
Tubercle,  79 
bacillus,  19 

adenoid     vegetations     as     port     of 

entrance,  415 
and     lepra     bacillus,     resemblance, 

21 
channels  of  entrance,  36 
chemic  composition,  25 
conditions  influencing  infection  after 

exposure  to,  72 
cultural  characteristics,  22 
distribution,  55 

in  body,  36 
effect  of  sunlight  on,  23 
means  of  exit,  36 
on  hands,  514 

relation  of  human  and  bovine,  27 
staining,  20 

tonsils  as  port  of  entrance,  415 
various  types,  25 


778 


Tubercle  bacillus,  virulence,  as  determin- 
ing course  of  disease,  76 
vitality,  22 
conglomerate,  79,  83 
corpuscle,  18 
crude,  83 

degenerative  clianges  in,  81 
reticulum  of,  SO 
submiliary,  79,  S3 
Tuberculin  and  immunity,  727 
test,  247 
T  O,  728 
T  R,  728 
Turban-shaped  epiglottis,  532 
Tympanitic  resonance,  178,  188 
Typhoid    fever    and    meningeal    tuber- 
culosis, differentiation,  344 
phthisis  following,  101 
type  of  miliary  tuberculosis,  331 

Ulcerative  type  of  cutaneous  tuber- 
culosis, 521 
of  tuberculosis  of  intestine,  468 
of  vermiform  appendix,  471,  472 
Ureteral  catheterization  in  diagnosis  of 

renal  tuberculosis,  495 
Urine  in  renal  tuberculosis,  492 

segregation  of,  in  diagnosis  of  renal 
tuberculosis,  495 
Uterus,  tuberculosis  of,  511 
symptoms,  512 
treatment,  512 

Vaccines,  bacterial,  in  mixed  infection, 
549 
in  tuberculosis,  738 
Varieties,  94,  147 
Vegetations,  adenoid,  as  port  of  entrance 

for  tubercle  bacillus,  415 
Venesection   and   salt   solution    in   pul- 
monary hemorrhage,  720 
Vermiform  appendix,  tuberculosis  of,  471 
clinical  symptoms,  473 
hyperplastic  form,  471,  473 
illustrative  cases,  477 
primary,  472 

principles  of  management,  474 
ulcerative  type,  471,  472 
Verruca  cutis,  513 
necrogenica,  513 
Vesical  tuberculosis,  488,  499.     See  also 
Bladder,  tuberciUosis  of. 


Vesicles,  seminal,  tuberculosis  of,  505 
Vesicular  rales,  212,  213 
crackling,  212 
dry,  212 
resonance,  178 

respiration,  auscultation,  199,  200 
regional  differences,  201 
Vesiculocavernous  respiration,  208 
Virulence  of  tubercle  bacillus  as  deter- 
mining course  of  disease,  76 
Visitation,  domiciliary,  585 
Vocal  fremitus,  174 
diminished,  175 
increased,  175 
resonance,  changes  in  intensity,  215 
in  pitch  and  quality,  216 
increased,  215 

modifications,  in  disease,  215 
over  larynx,  203 
over  lung,  203 
over  trachea,  203 
suppression  or  diminution,  215 
Voice,  amphoric,  216 
cavernous,  216 

spoken,  modifications,  in  disease,  215 
symptoms,  108 
whispered,  203 

intensification,  in  moderate  involve- 
ment, 228 
modifications,  in  disease,  217 
Voice-sounds,  normal,  202 
Vomiting  and  cough,  103 


Walking    in    open    air    in    treatment, 

621 
Wart,  anatomic,  513 

necrogenic,  513,  521 
Weight,  loss  of.  115 

diagnostic  import,  241 
What  the  public  should  know,  595 
Whispered  voice,  203 

intensification,  in  moderate  involve- 
ment, 228 
modifications,  in  disease,  217 
William's  tracheal  tone,  189 
Window-tent,  Knopf's.  627 
Wintrich's  change  of  pitch,  190 
Wooden  shelters  in  treatment,  631,  632, 

633 
Workshops,   hygienic   construction   and 
sanitary  supervision,  in  prophylaxis, 
605 


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Todd's  Clinical  Diagnosis 


Manual  of  Clinical  Diagnosis.  B\-  J.xmes  Campbell  Todd, 
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Anders' 
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DaCosta's   Physical   Diagfnosis 


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McKenzie  on  Exercise  in 
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Goepp's 
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Sahli's  Diagnostic  Methods 

Editors:  Francis  P.Kinnicott,  ]VI.D.,and  Nath'I  Bo wditch  Potter, M.D. 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof. 
Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by  Francis  P.  Kinni- 
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ILLUSTRATED 

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ne.  Johns  Hopkin. 

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to  recommend  i 

t  to  ou 

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Friedenwald  and  Ruhrah 
on  Diet 


Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
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George  Dock.  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulane   University. 
••  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available. 
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PRACTICE    OF   MEDICINE 


Rolleston  on  the  Liver 


Diseases  of    the   Liver,   GalUbladder,   and    Bile-ducts.     By   H. 

D.  Rolleston,  M.  D.  (Cantab),  F.  R.  C.  P.,  Physician  to  St.  George's 
Hospital,  London,  England.  Octavo  volume  of  794  pages,  fully  illus- 
trated, including  a  number  in  colors.     Cloth,  ^6.00  net. 

INCLUDING    GALL-BLADDER    AND    BILE-DUCTS 

This  work  covers  the  entire  field  of  diseases  of  the  hver,  and  is  the  most 
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past  devoted  his  time  exclusively  to  diseases  of  the  digestive  organs,  and  any- 
thing from  his  pen,  therefore,  is  authoritative  and  practical.  Special  attention  is 
given  to  pathology  and  treatment,  the  former  being  profusely  illustrated. 

Medical  Record.  New  York 

"The  most  extensive  treatise  on  diseases  of  the  Hver  yet  published  in  English.  ...  It  re- 
flects an  unusual  degree  of  experience  in  a  difficult  but  highly  important  branch  of  study." 


Boston's 
Clinical  Diagnosis 

Clinical  Diagnosis.  By  L.  Napoleon  Boston,  M.D.,  Adjunct 
Professor  of  Medicine  and  Director  of  the  Clinical  Laboratories,  Med- 
ico-Chirurgical  College,  Philadelphia.  Octavo  of  563  pages,  with  330 
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THE  NEW  (2d)  EDITION.  ENLARGED 
TWO    EDITIONS    IN    ONE    YEAR 

Dr.  Boston  here  presents  a  practical  manual  of  the  clinical  and  laboratory 
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however,  which  can  be  carried  out  by  the  busy  practitioner  in  his  office  as  well 
as  by  the  student  in  the  laboratory.  In  this  new  second  edition  the  entire  work 
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Boston  Medical  and  Surgical  Journal 

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SAUNDERS'    BOOKS    ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 


li.NIIER    THE    EDITORIAL    bUPERVTSION    UK 

ALFRED   STENGEL,  M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 


■  acknowledged  that  the  Gern 


thi; 


suhj 


ns  lead  the  world  in  Internal  Medicine  ;  and 
igel's   '■  Specielle  Pathologie  und  Therapie  " 


BEST  IN 
EXISTENCE 


is  coiUL-dcd  by  scholars  ' 
of  Meilicine  in  existence, 
of  Internal  Medicine  thai 
original  German.     In  vie\ 


0  be  without  question  the  best  Practice 
So  necessary  is  this  book  in  the  study 

it  comes  largely  to  this  country  in  the 

1  of  these  facts,  Messrs.  W.  B.  Saunders 


FOR    THE 
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Company  arranged  with  the  publishers  of  the  German  edition  to 
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for  the  General  Practitioner. 
The  work  has  been  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  has  been  edited  by  a  prominent  specialist.  It  has  thus  been  brought 
thoroughly  up  to  date,  and  the  American  edition  is  more  than  a  mere  translation  ;  for,  in  addi- 
tion to  the  matter  contained  in  the  original,  it  represents  the  very 
latest  views  of  the  leading  American  and  English  specialists  in  the 
various  departments  of  Internal  Medicine.  Moreover,  as  each 
volume  has  been  revised  to  the  date  of  its  publication  by  the 
eminent  editor,  the  objection  that  has  heretofore  existed  to  treatises 
published  in  a  number  of  volumes  has  been  obviated,  since  the  subscriber  receives  the  com- 
pletedwork  while  the  earlier  volumes  are  still  fresh.  The  American  publication  of  the  entire 
work  is  under  the  editorial  supervision  of  Dr.  Alfred  STENGEL,  who  has  selected  the  subjects 
for  the  .American  Edition,  and  has  chosen  the  editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a  publication  of 
this  kind  has  been  to  require  physicians  to  take  the  entire  work. 
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purchasing  this  Practice  physicians  are  given  the  opportunity  of 
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ber of  volumes,  each  complete  in  itself,  may  be  obtained  by  those  who  do  not  desire  the  com- 
plete series.  This  latter  method  offers  to  the  purcha.scr  many  advantages  which  will  be 
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Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmann,  of  Leipsic.  The  entire  volume  edited,  with 
additions,  by  William  Osler,  M.  D.,  F.  R.  C.  P.,  Regius  Professor  of  Med- 
icine, Oxford  University,  Oxford,  England.  Octavo  volume  of  646  pages, 
fully  illustrated. 

Smallpox  ( including  Vaccination ),  Varicella,  Cholera  Asiatica. 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  Dr.  H.  Immermann,  of  Basle  ;  Dr.  Th.  von  Jurre.nsen,  of  Tubingen  ; 
Dr.  C.  Liebermeister,  of  Tubingen  ;  Dr.  H.  Lenhartz,  of  Hamburg  ; 
and  Dr.  G.  Sticker,  of  Giessen.  The  entire  volume  edited,  with  additions, 
by  Sir  J.  W.  Moore,  M.D.,  F.  R.  C.  P.  1.,  Professor  of  Practice,  Royal  Col- 
lege of  Surgeons,  Ireland.      Octavo,  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  of  New  York,  and  Dr.  Th.  von  JiJR- 
GENSEN,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by  William 
P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  Octavo,  672  pages,  illustrated,  including 
24  full-page  plates,  3  in  colors. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  Inflam- 
mations of  the  Lun£(s 

By  Dr.  F.  A.  HoFF^L\NN,  of  Leipsic  ;  Dr.  O.  Rosenbach,  of  Berlin  ;  and 
Dr.  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo,  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic   plates. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  of  Vienna  ;  Dr.  E.  Neusser,  of  \'ienna,  and  Drs.  H. 
Quincke  and  G.  Hoppe-Seyler,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  Reginald  H.  Fritz,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  Frederick  A. 
Packard,  M.  D.,  Late  Physician  to  the  Pennsylvania  and  Children's  Hos- 
pitals.     Octavo  of  918  pages,  illustrated. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D.,  Professor  of  Medicine,  liniversity  of  Buffalo.  OcUvo  of 
835  pages,  with  29  text-cuts  and  6  full-page  plates. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  The  entire  volume  edited,  with 
additions,  by  H.  D.  Rolleston,  M,  D.,  F.  R.  C.  P..  Physician  to  St.  George's 
Hospital,  London.      Octavo  of  iioo  pages,  finely  illustrated. 


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Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

ISy  Dr.  G.  Cornet,  of  Berlin.  Edited,  with  additions,  by  Walter  B. 
James,  M.  D.,  Professor  of  the  Practice  of  Medicine,  ColuiBbia  University, 
New  York.      Octavo  of  806  pages. 

Diseases  of  the  Blood   '  .-tnemiti,  chlorosis.  Leukemia,  and  Pseudoleukemia) 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of  Char- 
lottenburg ;  Dr.  K.  von  Noorden,  of  Frankfort-on-the-Main  ;  and  Dr. 
Feli.x  Pinkus,  of  Berlin.  The  entire  volume  edited,  with  additions,  by  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
Octavo  of  714  pages,  with  text-cuts  and  13  full-page  plates,  5  in  colors. 
Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstern,  of  Cologne. 
The  entire  volume  edited,  with  additions,  by  Ronald  Ross,  F.  R.  C.  S.  (Eng.), 
F.  R.  S.,  Professor  of  Tropical  Medicine,  University  of  Liverpool  ;  J.  W.  W. 
Stephens,  M.  D.,  D.  P.  H.,  Walter  Myers  Lecturer  on  Tropical  Medicine, 
University  of  Liverpool  ;  and  Albert  S.  Grunbaum,  F.  R.  C.  P.,  Professor 
of  Experimental  Medicine,  University  of  Liverpool.  Octavo  of  769  pages, 
illustrated. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator,  of  Berlin,  and  Dr.  M.  Litten,  of  Berlin.  The  entire 
volume  edited,  with  additions,  by  James  B.  Herrick,  M.  D.,  Professor  of  the 
Practice  of  Medicine,  Rush  Medical  College.     Octuvo  of  815  pages,  illust. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgensen,  of  Tiibingen  ;  Prof.  Dr.  L.  Krehl, 
of  Greifswald  ;  and  Prof.  Dr.  L.  von  SchrOtter,  of  Vienna.  The  entire 
volume  edited,  with  additions,  by  George  Dock,  M.  D.,  Professor  of  Theory 
and  Practice  of  Medicine  and  Clinical  Medicine,  Tulane  University  of 
Louisiana.     Octavo  of  848  pages,  fully  illustrated. 


SOME  PRESS  OPINIONS 


London  Lancet  ( Typhoid  volume) 

'■  We  welcome  the   translation  into  English  of  this  excellent  practice  of  medicine.     The 
first  volume  contains  a  vast  amount  of  useful  information,  and  the  forthcoming  volumes  are 
awaited  with  interest." 
Journal  American  Medical  Association  (  Tuberculosis  volume) 

"We  know  of  no  single  treatise  covering  the  subject  so  thoroughly  in  all  its  aspects  as 
this  great  German   work.  ...   It   is  one   of  the  most  exhaustive,  practical,   and  satisfactory 
works  on  the  subject  of  tuberculosis." 
Medical  News,  New  York  {Liver  volume) 

"  Leaves  nothing  to  be  desired  in  the  way  of  completeness  of  information,  orderly  arrange- 
ment of  the  text,  thoroughgoing  up-to-dateness,  handiness  for  reference,  and  exhaustive  dis- 
cussion of  the  subjects  treated." 

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MA  TERIA      MED/CA. 


Stevens' 
Modern    Therapeutics 


A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics.     By 

A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on   Physical  Diagnosis  in  the 
University  of  Pennsylvania.     Octavo  of  670  pages.     Cloth,  $3.50  net. 

THE      NEW     (4th)     EDITION 
Adapted  to  the  New  ( I905)  Phairmacopeia 

Dr.  .Stevens,  by  his  extensive  teaching  experience,  has  acquired  a  clear, 
concise  diction  that  adds  greatly  to  his  work's  pre-eminence.  In  this  edition 
new  articles  have  been  added  on  Scopolamin,  Ethyl  Chlorid,  Theocin,  Veronal, 
and  Radium,  besides  much  new  matter  to  the  section  on  Radiotherapy.  The 
numerous  changes  in  name  or  strength  of  various  drugs  and  preparations,  as 
called  for  by  the  new  Pharmacopeia,  have  also  been  made.  The  work  includes 
the  following  sections  :  Physiologic  Action  of  Drugs  ;  Drugs  ;  Remedial  Measures 
other  than  Drugs  ;  Applied  Therapeutics  ;  Incompatibility  in  Prescriptions  ;  Table 
of  Doses  ;  Index  of  Drugs  ;  and  Index  of  Diseases  ;  the  treatment  being  eluci- 
dated by  more  than  two  hundred  formulae. 

University  Medical  Magazine 

"  The  author  has  faithfully  presented  modern  therapeutics  in  J  comprehensive  work  .  .  . 
and  it  will  be  found  a  reliable  guide  and  sufficiently  comprehensive." 


Camac's 

Cpoch-Making  Contributions 

Epoch-Making   Contributions    in    Medicine   and    Surgery.      Col- 
lected and  arranged  by  C.   N.   B.  Camac,  M.  D.,  of  New  York  City. 
Octavo  of  450  pages,  illustrated.     Artistically  bound,  $4.00  net. 
RECENTLY     ISSUED 

Dr.  Camac  has  collected  some  of  the  most  important  epochal  articles  in 
medicine  and  surgery — articles  that  record  masterpieces  of  scie7iiific  research — and 
has  presented  them  in  the  original,  together  with  a  portrait  and  a  brief  biographic 
sketch  of  the  discoverer.  The  articles  included  are  :  Antisepsis  (Lister),  Circula- 
tion (Harvey),  Percussion  (Auenbnigger),  Auscultation  (Laennec),  Anesthesia 
(Morton),    Puerperal   Fever    (Holmes),  Vaccination  (Jenner). 


SAUNDERS'     BOOKS    ON 


Amy's 
Principles  qf  Pharmacy 


Principles  of  Pharmacy.     By  Henry   V.   Arny,    Ph.  G.,   Ph.  D., 

Professor  of  Pharmacy  at  the  Cleveland  School  of  Pharmacy.     Octavo 
of  I200  pages,  with  250  original  illustrations. 

READY  IN   JUNE 

Professor  Arny  divides  his  subject  into  seven  parts  :  The  first  part  deals  with 
pharmaceutic  processes,  a  striking  feature  being  the  clear  discussion  of  the  arith- 
metic of  pharmacy  ;  the  second  part  deals  with  galenic  preparations  of  the  Phar- 
macopeia and  those  unofficial  preparations  of  proved  value  ;  the  third  part  deals 
with  the  inorganic  chemicals  used  in  pharmacy,  and  includes  also  a  chapter  on 
chemical  theories  and  chemical  arithmetic  ;  the  fourth  part  discusses  the  organic 
chemicals  used  in  pharmacy,  the  most  modern  classification  being  adopted  ;  the 
fifth  part  is  devoted  to  chemical  testing,  presenting  a  systematic  grouping  of  all 
the  tests  of  the  Pharmacopeia — a  feature  not  found  in  any  other  book  ;  the  si.xth 
part  discusses  the  prescription  from  the  time  it  is  written  until  it  is  dispensed  ;  the 
seventh  part  is  devoted  to  laboratory  work,  a  feature  being  the  e.xercises  in  equa- 
tion writing  and  chemical  arithmetic. 


Hatcher   and  Sollmann's 
Materia  Medica 

A  Text-Book  of  Materia  Medica  :  including  Laboratory  Exercises 
in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert  A. 
Hatcher,  Ph.  G.,  M.  D.  ;  and  Torald  Sollmann,  M.  D.  i2mo  of 
411  pages.     Flexible  leather,  $2.00  net. 

Eichhorst's  Practice 

A  Text-Book  of  tlie  Practice  of  Medicine.  By  Dr.  H.  Eichhor.st, 
University  of  Zurich.  Fidited  by  A.  A.  Eshner,  M.  D.  Two  octavos 
of  600  pages  each,  with  150  illustrations.     Per  set:  Cloth,  $6.00  net. 


MA  TERIA    MEDICA. 


Sollmann's  Pharmacology 

Including  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription-writing',  Toxicology,  etc. 


A  Text-Book  of  Pharmacology,  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Medical  Department 
of  Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo 
volume  of  1070  pages,  fully  illustrated.     Cloth,  $400  net. 

THE    NEW    (2d)    EDITION 

Because  of  the  radical  alterations  which  have  been  made  in  the  new  (1905) 
Pharmacopeia,  it  was  found  necessary  to  reset  this  book  entirely.  The  author 
bases  the  study  of  therapeutics  on  a  systematic  knowledge  of  the  nature  and 
properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  P.  Poiheringham.  M.  D. 

Pyof.  of  Therapeutics  and  Theory  and  Practice  of  Prescribing    Trinity  Med.  College,  Toronto. 
"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Butler's   Materia   Medica 

Therapeutics,  and  Pharmacology 


A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 

By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head  of  the 
Department  of  Therapeutics  and  Professor  of  Preventixe  and  Clinical 
Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical  Depart- 
ment Valparaiso  University.  Octavo  of  702  pages,  illustrated.  Cloth, 
^4.00  net ;   Half  Morocco,  ^5.50  net. 

RECENTLY     ISSUED— NEW    (6th)    EDITION 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part 
having  been  rewritten.  All  obsolete  matter  has  lieen  eliminated,  and  special  atten- 
tion has  been  given  to  the  toxicologic  and  therapeutic  effects  of  the  newer  com- 
pounds. The  classification  adopted  is  a  practical  one,  aiding  the  student  in  grasp- 
ing the  subject,  and  the  practitioner  in  finding  the  information  sought. 

Medical  Record.  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the  com- 
pleteness of  the  te.Kt,  and  the  student  or  general  reader  is  given  the  benefit  of  latest  advices 
bearing  upon  the  value  of  drugs  and  remedies  considered." 


saujXders'  books  on 


Thornton's   Dose-Book 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  Thorn- 
ton, M.  D..  Assistant  Professor  of  Materia  Medica,  Jefferson  Medical 
College,  Phila.  Post-octavo,  392  pages,  illustrated.  Flexible  Leather, 
g2.oo  net. 

The    New   (3d)   Edition 

Dr.  Thornton,  in  making  this  revision,  has  brought  his  book  in  accord  with 
the  new  (1905)  Pharmacopeia.  Throughout  the  entire  work  numerous  references 
have  been  introduced  to  the  newer  curative  sera,  organic  extracts,  synthetic  com- 
pounds, and  vegetable  drugs.  To  the  Appendix,  chapters  upon  Synonyms  and 
Poisons  and  their  antidotes  have  been  added,  thus  increasing  its  value  as  a  book 
of  reference. 

C.  H.  MUler.  M.  D., 

Professor  of  Pharmacology ,  Northwestern  University  Medical  School,  Chicago. 
"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


Lusk  on   Nutrition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.D., 
Professor  of  Physiology'  in  Cornell  University  Medical  School.  Octavo 
of  325  pages.  Cloth,  $2.50  net. 

This  practical  work  deals  with  the  subject  of  nutrition  from  a  scientific  stand- 
point, and  will  be  useful  to  the  dietitian  as  well  as  the  clinical  physician.  There 
are  special  chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metab- 
olism. 

Lewellys  T.  Barker.  M.D.. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly.      It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 


Mathews'  How  to  Succeed  in  Practice 

How  to  Succeed  in  the  Practice  of  Medicine.  By  Joseph  M. 
Mathews,  M.D.,  LL.D.,  President  American  Medical  Association, 
1898-99.     l2mo  of  215  pages,  illustrated.     Cloth,  $1.50  net. 


PRACTICE.   MATERIA    MEDIC  A,  Etc. 


15 


The  American  Pocket  Medical  Dictionary.  just  Ready 

The  American  Pocket  Medical  Dictionary.  Edited  bv  W.  A.  Newman  D.ir- 
LANI>,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  tlie  University  of  Pennsylvania. 
Containing  the  pronunciation  and  definition  of  the  principal  words  used  in  medicine 
and  kindred  sciences,  with  64  extensive  tables.  Flexible  leather,  with  gold  edges, 
jSl.oo  net ;  with  thumb  index,  $1.25  net. 

"I  can  recommend  it  to  our  students  without  reserve."— J.  H.  Holland.  M.  D.,  0/  the  Jefferson 
Mldicat  College.  Philadelphia. 

Pusey  and  Caldwell  on  X-Rays  second  Edwon 


The  Practical  Application  of  the  Kontgen  Rays  in  Therapeutics  and 
Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois;  and  Eugene  W.  Caldwell,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  p.iges,  with  200  illustrations.  Cloth,  jtS-OO  net ; 
Half  Morocco,  $6.50  net. 

"  It  is  indispensable  to  those  who  use  the  X-rays  as  a  therapeutic  agent  ;  and  its  illustrations  are  so 
numerous  .  .  .  that  it  becomes  valuable  to  every  one." — Boston  Medical  and  Su7-^cal  Journal. 

Cohen  and  Eshner's  Diagnosis.     Second  RevUed  Edition 

Essentials  of  Diagnosis.  By  S.  SoLis-Cnni  \,  M.  1 1,,  >.  uior  Assistant  Professor 
in  Clinical   Medicine,  Jefferson  Medical  Coll,,--.   1  ',,  1  A.  A.  EsHNER,  M.  D., 

Professor  of  Clinical   Medicine,  Philadelphia    I-;.     1    i  !       1  ..ctavo,  3S2  pages;   55 

illustrations.      Cloth,  gl. 00  net.      In  SnuiiJen'  {^.i    :.   /i  i     "jiul  Series. 

of  subject,  terse    in   expression    of  fact."— Awerican  Journal  0/  the 


Morris'  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Theraphutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W'.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  I2ino,  300}>ages.  Cloth,  ^I.oo  net.  In  Saunders^ 
Question-  Compend  Series. 
"  Cannot  fail  to  impress  the  mind  and  instinct  in  a  lasting  manner."— fi«^i/(i  Medical  Journal. 

Williams*  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  Williams,  M.D., 
formerly  Instructor  in  Medicine  and  Lecturer  on  Hygiene,  Cornell  University  ;  and 
Tutor  in  Therapeutics,  Columbia  University,  N.  Y.  l2mo  of  456  pages,  illustrated. 
In  Saunders'  Question-Compend  Series.     Double  number,  $1.75  net. 

Stoney's  Materia  Medica  for  Nurses  New  ,3rd)  Edition 

Materia  Medica  for  Nurses.  Bv  Emily  A.  M.  Stoney,  Superintendent  of  the 
Training  School  for  Nurses  at  the  Carney  Hospital,  South  Boston,  Mass.  Handsome 
i2mo  volume  of  300  pages.     Cloth,  $1.50  net. 

"It  contains  about  everything  that  a  nurse  ought  to  know  in  regard  to  A-ryi^^."— Journal  0/  the 
American  Medical  Association. 

Grafstrom's  Mechano-therapy  second  Edition.  Enlarged 

A  Text-Book  of  Mechano-therapy  (Massage  and  Medical  Gvmnasticsl.  Bv 
Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  Attending  Physician  to  Augustus  Adolphus  Orphan- 
age, Jamestown,  N.  Y.     i2mo.  200  pages,  illustrated.     51.25  net. 

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Date 

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1908 
Bonney,  Sherman  G. 

Pulnonary  tuberciaosis 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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